Chap 7

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I The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies
Control of communicable diseases
This measles 'jab' will help prevent this child from the consequences of measles such as pneumonia, malnutrition, blindness and brain disease. Photo:Marko Kokic,Canadian Red Cross
Public health guide for emergencies I 285
Description
This chapter gives an overview of common and emerging communicable disease threats among displaced populations because of natural and human-made disasters. General and disease-specific strategies for monitoring, preventing and controlling disease outbreaks are discussed.
Learning objectives
To review communicable diseases of public health importance; To discuss the basic principles for communicable disease control in emergency and post-conflict situations; To plan a communicable disease control programme for emergency settings; To discuss simple but effective ways of preventing outbreaks of communicable diseases; To describe how to manage specific disease outbreaks in emergency settings; To review re-emerging and other diseases that may affect displaced populations; To discuss how to monitor and evaluate communicable disease control programmes.
Key competencies
Identify communicable diseases of public health importance; Discuss the basic principles for communicable disease control in emergency and post-conflict situations; Discuss how to design and evaluate disease control programmes; Describe common disease control strategies including prevention, surveillance and outbreak investigation; Describe methods for promoting community-based and community-led communicable disease control approaches; Decide when to scale up and scale down disease control efforts; Discuss the causes, risk factors, clinical features and management of common diseases; Identify cases with zoonotic diseases and other re-emerging communicable diseases (such as SARS, bird flu, Ebola and Marburg) in emergency and non-emergency settings; Review key Monitoring and Evaluation (M&E) concepts, best practices and challenges; Design an M&E framework for malaria, Dengue, TB and HIV/AIDS control with standard indicators and tools; Explain the role of operational research and identify key areas for operational research in communicable disease control.
Control of communicable diseases in emergencies
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Introduction
Rapid and slow-onset natural disasters such as floods, earthquakes, hurricanes and droughts occur globally every year because of adverse weather conditions or poor land use. Climate change, together with population growth and urbanisation as well as ageing populations will increase the number of disasters, change the disease pattern. Furthermore, with an increased number of disasters, many governments will have an even bigger problem to recover a sense of normalcy and also cover the widening healthcare gaps due to high migration of health care staff to Europe and the US. External assistance will become even more important. Depending on their nature, duration and location, some natural disasters result in major disease outbreaks and deaths. Populations in developing countries are more disproportionately affected because of poverty, a lack of resources, poor infrastructure and inadequate disaster preparedness efforts. Communicable diseases also account for most of the reported deaths among conflict-affected populations due to displacement, malnutrition and limited access to basic needs. In addition to assessing the disease incidence and prevalence, the prevention and control of disease outbreaks require a thorough understanding of the environmental and host factors, the transmission pattern and other characteristics of causative organisms. More people are travelling more than ever worldwide; diseases and epidemics, therefore, will be more prone to spread rapidly. Communicable disease outbreaks respect no borders. Humanitarian actors must work closely with not only global bodies like WHO, Inter-Agency Standing Committee (IASC) cluster and local health authorities, but also the communities particularly when planning and implementing disease control programmes. Preferably one can prevent communicable disease outbreaks by engaging the communities and ensuring early detection and alert. Implementing disease control measures is quite straightforward provided one knows the starting point, the arrival point and how to get there. Without an effective monitoring of engaged communities and evaluation systems, measuring and reporting ones progress and the final result might be difficult. In addition, further research on the effectiveness of proposed interventions and the testing of new preventive or treatment measures will enhance national policies and guidelines as well as the reallocation of resources among various stakeholders.
Communicable diseases as public health threats

An epidemic is defined as the occurrence of cases of an illness with a frequency that is clearly in excess of what is expected in a given region, therefore, demanding emergency control measures. It might be preferable to report it as an outbreak because it appears to cause less panic than epidemic. The media often reports that disease epidemics or outbreaks are imminent after natural disasters such as flooding, hurricanes and earthquakes. However, humanitarian actors should not necessarily rely on what is reported by the media or other channels since there are common patterns in various types of disasters. Lessons learnt from similar situations can be used to predict when and which diseases are likely to cause epidemics. Outbreaks of diarrhoeal diseases have been reported after natural disasters particularly in developing countries with limited resources. However, disease outbreaks or epidemics do not occur spontaneously unless certain
Water distribution at a refugee camp (Photo: Emily Christensen)
Disease outbreaks, rather than trauma, have also been the major cause of deaths in emergency and post-conflict situations, sometimes raising baseline death rates sixty times (Lancet, M. Connelly et al). Over the past decade, the top killers in most complex emergencies (apart from many deaths related to pregnancy and childbirth) have been malaria, diarrhoeal diseases and pneumonia with TB and HIV/AIDS gaining increasing attention more recently. During the acute emergency phase, over 40% of deaths in camp situations are caused by diarrhoeal diseases, 80% of them among children below two years of age. Similar patterns occur in post disaster situations, where there are no camps at all. Because measles epidemics have declined since the 1990s, they are often overlooked in disasters. Yet wherever there is a major population displacement, there are see outbreaks even in countries claiming up to 90% immunisation coverage. Several conflict-affected countries reportedly have measles coverage below 50% and widespread outbreaks have been reported in Ethiopia, Democratic Republic of Congo (DRC) and Afghanistan. An estimated 30% of the 1 million deaths due to malaria occur annually in conflict affected countries in Africa and a massive malaria epidemic is reported to have affected 2.8 million among Burundis population of 7 million people. There is now evidence that malaria patients are more prone to acquiring HIV infection and vice versa. In 2002 during the dry season, several meningitis outbreaks were reported beyond the traditional meningitis belt into Rwanda, Burundi and Tanzania. Other diseases may become a bigger problem during the post-emergency phase. Over 80% of refugees originate from or settle in countries with a high burden of TB. Poor Directly Observed Therapy Short Course (DOTS) implementation might increase the risk of multi-drug resistant TB while the spread of HIV has reversed the declining epidemiologic curve. Many HIV-endemic countries in sub-Saharan Africa report more than 50% of TB patients have HIV and the situation is worsening due to the emergence of a new strain of Extreme Drug Resistance TB (XDR TB) that is not responsive to routine anti-TB treatment. Finally, every year up to four emerging bacterial and viral infections emerge, contributing to the global threat for pandemics. Some of them are not viscous, but others are associated with high case fatality rates such as SARS, bird flu and viral haemorrhagic fevers. Experience has shown that the risk of disease outbreaks and deaths during natural disasters and complex emergencies might be minimised through early introduction of disease surveillance, epidemic preparedness, effective prevention and control including case management. Early detection, reporting and response are vital to limit the spread of outbreaks and epidemics. Failure to implement timely, effective and coordinated measures might result in the following: Re-emergence of old disease threats (malaria, TB); Outbreaks of changed disease patterns (e.g. malaria, meningitis, yellow fever, chikungunya, Dengue); Outbreaks due to changed vulnerability such as heavy urbanisation with more shanty towns (West Africa, India, Latin America and others); Further spread of neglected diseases (such as Guinea worm, cholera, leischmaniasis, sleeping sickness, leprosy, etc.); High morbidity and mortality from delayed epidemic detection and response (e.g. dysentery, meningitis); Emergence of a few super bugs which are resistant to all antibiotics. They were limited to hospitals previously, but are now circulating in communities;
factors are present to promote disease transmission in the local environment. Large-scale displacement is a key factor contributing to disease outbreaks after a natural disaster particularly among populations that are very poor and greatly lack access to basic needs such as food, shelter, safe water, sanitation and health care including vector control measures.
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Emergence and spread of new pathogens and diseases (e.g. monkey pox in DRC, SARS, Nipah, bird flu); Persistence or even spread of diseases targeted for eradication (polio, leprosy, Guinea worm).
Principles of communicable disease control

A communicable disease is defined as an illness that arises from transmission of an infectious agent or its toxic product from an infected person, animal or reservoir to a susceptible host, either directly or indirectly through an intermediate plant or animal host, vector, or environment. Note: Communicable and infectious have the same meaning; both terms are used interchangeably throughout this chapter.
Basic principles
A disease epidemic or outbreak occurs when there are more people suffering from a particular illness than what would normally be expected. Therefore, emergency control measures are needed. It is incorrectly assumed that epidemics and plagues are inevitable after every disaster. The threat of communicable disease outbreaks is greater after a disaster than in non-emergency situations particularly when large populations have been displaced. However, an epidemic or outbreak will only occur if the equilibrium is changed between the populations susceptibility (host or reservoir), the virulence of the infectious agent (bacteria, viruses, parasites, or fungi or their products) and the environment that promotes the exposure are upset (refer to Figure 7-1 below).
Figure 7-1: Equilibrium between the population, infectious agent, and the environment
POPULATION Age Genetic make up Poverty Nutritional status Previous exposure Immunisation status General physical condition AGENT Virulence Infectious dose Susceptibility to drugs Mode of transmission Ability to adapt to change
ENVIRONMENT Shelter Altitude Humidity Sanitation Food supply Water supply Climate change Overcrowding Essential services
Although each emergency situation is unique, all emergencies are surrounded by the same factors that can upset the balance between the infectious agent, the host and the environment, as follows:
Agent
Note: A disease outbreak will not occur if an infectious agent of a particular disease is not present in the environment and is not introduced after a disaster, even if environmental conditions are ideal for transmission.
Population
Displaced persons might change the local environment or bring new or different strains of infectious agents. Displaced persons might also have low immunity to infections caused by a poor physical or nutritional status, underlying diseases or poverty. Certain individuals are more vulnerable to infectious diseases or the more severe form of the illness. Immunity deprived persons like those with poor nutrition, TB or HIV are an example. Children less than five years of age (usually about 20% of the displaced population) and the elderly are at the greatest risk of morbidity and mortality from infectious diseases particularly the malnourished. Initial assessment and ongoing surveillance is critical to identify the most at risk groups so that they can be protected.
Environment
Opportunities for infection might increase because of overcrowding, unhygienic conditions, a lack of safe drinking water, climate change, insecurity etc. Essential public health or medical services might also have been inadequate before the disaster and, subsequently, disrupted or overwhelmed by the emergency situation as a result of the breakdown of the health infrastructure and displacement of skilled health workers who might also experience a loss of family, property etc. Large population movements from one malaria endemic area to another might increase the risk for severe malaria among the displaced as well as the host population if the malaria species affecting the two populations are somewhat different. Note: Because communicable diseases respect no boundaries. Outbreaks occurring within the displaced population can spread to the host population, and vice versa. The above risk factors can apply to either population. The probability of communicable disease outbreaks occurring depends, therefore, on the type of infectious agents existing within the local environment and the displaced populations physical condition and health status. Sometimes it is easier to undertake control measures for disease outbreaks that affect a closed settlement such as a refugee or Internally Displaced Persons camp. Unfortunately for most epidemics related to natural disasters, people are not always in camps but dispersed within a host population. Targeting high risk persons in such a mixed setting might be challenging. Extreme poverty can also force these high risk groups to eventually move to camp settings thus increasing their vulnerability.
Communicable disease cycle

Communicable diseases do not always develop in the same way in susceptible hosts. Some diseases produce more non-clinical cases that experience vague, non-specific symptoms or none at all (e.g., TB, cholera, polio) and thus spread the disease without being aware. Other diseases produce more clinical cases with easily detectable symptoms (e.g. measles). However, once exposed, people with as well as people without clinical or
Infectious disease agents are constantly developing where it is possible to multiply most easily either in susceptible persons, vectors, animals or in the environment. Because their genes are mutated/changed at random quite rapidly, new features appear that might be better adapted to the environment and able to spread to new locations, disappear to reappear and infect more vulnerable populations. Some infectious agents cause higher rates of illness and death because they have become resistant to available treatment (e.g., TB, malaria) or are more virulent, leading to major outbreaks (e.g. Shigella, Ebola, SARS).
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biological signs of infection are capable of spreading the disease to other susceptible persons. Such people are known as carriers. The figure below illustrates the cycle of communicable disease progression in susceptible hosts/persons. Understanding the unique pace of specific communicable diseases through the cycle helps to identify those individuals that are likely to transmit the disease as well as those at greatest risk of becoming ill or dying within the population.
Figure 7-2: The communicable disease cycle
Non-diseased state
Death
Recovery immunity
Risk and exposure factors
Progression of disease
Communicable disease cycle

Susceptibility to the disease Clinical illness
Biological evidence of infection
Some diseases spread very rapidly (within a few hours), while other diseases spread insidiously, triggering a range of effects that might be felt on a wider scale. For example, cholera spreads rapidly and within a very short time, the whole community has been exposed. The opposite situation is that although less than 5% of a population might be infected with HIV, the effects will gradually spread from the individual and household levels to the community. Because People Living with HIV (PLHIV) infection progress from the asymptomatic phase to develop opportunistic infections, then AIDS and finally succumb to death, they might leave behind many other HIV infected family members and AIDS orphans. Analyzing each stage of a particular disease progression together with other sectors helps identify all possible points for disease control both more holistically and comprehensively.
General approach to setting up disease control programmes

Designing a disease control programme
The aim of disease control programmes (prevention and treatment) is to reduce excess morbidity and mortality by limiting the spread of diseases of epidemic potential. Proposed interventions will usually include adequate quantities of safe water, sanitation, nutritional services, reproductive health, food aid/food security, shelter and basic clinical care. In addition to considering the effectiveness, feasibility, cost, and speed of implementation of proposed intervention, it is important to consider how it will be integrated within the overall response as well as the culture and behaviour of target populations. A disease control programme may be designed using the approach described below.
Assessment
Rapid assessment
During the first days and week after a disaster, information is confusing, inconsistent and incomplete. Decisions have to be made based on incomplete data, prioritising and deciding where the needs are highest. Partially informed decisions must later be adjusted. Some organisations insist on waiting endlessly for more information and data, thus hampering vital decisions. It is better to work in consultation with the local government and other emergency responders to facilitate information sharing. If an Inter-Agency Standing Committee health cluster is established, this is the ideal forum to facilitate collection and sharing of information and subsequent data analysis. Many agencies are reluctant to share their data for various reasons. As soon as a rapid assessment has been carried out, it is important to keep the agency headquarters posted, while starting to mobilise the necessary staff, drugs and equipment.
In depth assessment
Within the shortest possible time and based on information priorities from the rapid assessment, in-depth assessments might be necessary. Planning a more comprehensive disease control programme must be based on these in-depth assessments. Gathering essential background information on the burden of communicable diseases and factors influences the outcome of common diseases. Other very important elements of disaster response to be included in a rapid assessment for communicable disease control include: psychological trauma and maternal and infant mortality and morbidity. These are wellcovered in other chapters. The following table provides a summary of the critical information that needs to be gathered during the assessment.
Table 7-1: Background information needed for planning disease control programmes
Demographic composition of the displaced population; Annual disease incidence rates of common diseases in the place of origin; Annual disease incidence rates of common diseases in the host country. Note that governments Health Information Systems are often unreliable and incomplete; Disease control policies in the place of origin are often not well known or well practiced; Disease control policies in the host country, are often not well-known or practiced; Standard case definitions and treatment protocols are often not well known and hard to get. Use WHO standards until further notice; Especially TB and HIV/AIDS policies, guidelines and protocols must be carefully evaluated and put into context. They often corresponds to WHO standards, but equally often not implemented in full. (lack of resources); Performance of specific disease control programmes in the place of origin; Performance of specific disease control programmes in the host country; Womens status and functions in families and communities; Displaced populations knowledge, cultural beliefs and treatment of communicable diseases; Knowledge and experience of health workers in the control of communicable diseases; Resources available for implementing a communicable disease control programme ; Capacity of local institutions and NGOs to implement a disease control programme; The local population condition and needs. After an in-depth assessment, representatives from the relief agency, the host authorities and the affected community might use the findings to plan an appropriate communicable
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disease control programme in a coordinated manner. If the host government cannot lead the process, a health cluster or other capable agency may be appointed to ensure good coordination.
Recovery assessment
Some long-term approaches may be explored during an in-depth assessment. The challenge is whether to include the health needs of the local population if this is the government mandate, unless really necessary. Another challenge is to decide whether the assistance should cover only the needs and gaps of services caused by the disaster or to address apparent needs present before the disaster. In particular, this will become more of an important issue as disasters become more frequent allowing less time for recovery between disasters and few opportunities for preparedness and reconciliation.
Select priorities
Because it is often impossible to carry out all the actions recommended by the assessment team, planners must determine what the priority interventions are. Specific criteria can be used to rank different public health measures and determine the top priorities for a relief operation. Suggested criteria include the seriousness of a problem (whether it is associated with high morbidity and mortality), the ease of implementation (which depends on the specialty or mandate of an agency), the availability of resources (human, financial etc.). The following table illustrates how interventions for top killer diseases in an emergency situation (Acute Respiratory Infections (ARIs), diarrhoea, malaria, measles and motherhood diseases) are ranked.
Table 7-2: Ranking public health measures
Public health measure Seriousness of problem 1 = minor 3 = major Ease of implementing 1 = difficult 3 = easy Availability of staff 1 = few 3 = many Cost of implementing 1 = high 3 = low Agency capacity 1 = low 3 = high Overall score
ORT for dehydration Sanitation build latrines Ensure access safe water via treatment and protecting sources Supply/treat mosquito nets, spraying Measles immunisation Ensure basic shelter Reproductive health Control TB via DOTS
3 3 3
3 2 3
3 3 2
3 2 2
3 2 2
15 12 12
11
3 3 3 2
3 3 2 1
2 3 2 1
3 2 2 2
2 2 2 2
13 13 11 8
The above exercise ranks Oral Rehydration Therapy (ORT), measles immunisation, shelter, safe water supply and building of latrines as the priority measures for an initial relief operation.
The ultimate goal of communicable disease control programmes is to identify risks and prevent excess mortality among the displaced population by preventing and managing outbreaks of communicable diseases. Even though preventive measures might prevent most of these deaths by reducing the incidence of disease outbreaks, they might not successfully prevent all outbreaks. If possible, prevent the outbreaks even from occurring and equally important is to be prepared to manage the outbreaks that do occur.
Goals
Prevent excess morbidity and mortality due to communicable diseases; Reduce the morbidity, mortality, and transmission of communicable diseases.
Objectives
The overall objective of an emergency response is to achieve a crude mortality rate of <1/10,000/day and an under-five mortality rate of < 2/10,000/day as soon as possible. Alternatively, the overall goal may be to reduce the Crude Mortality Rate to normal levels when it has doubled. Specific objectives for disease control programmes might vary according to the disaster situation and whether the period is emergency or post-emergency phase. Examples of an emergency phases objectives are: Emergency phase: Immunise more than 90% of all children in the target group for measles; Reduce the incidence of acute respiratory infections to pre-disaster levels in three months; Keep the case-fatality rate of acute watery diarrhoea/cholera at less than 1%; Halve the burden of severe malaria cases; Reduce maternal, neonatal and infant mortality rates by 25%. Examples of a post emergency phases objectives are: Ensure that at least 85% of identified TB cases are cured and to detect at least 70% of existing cases; Double the number of people with comprehensive HIV knowledge and access to preventive measures (condoms, counselling and testing and nutritional counselling for the HIV infected).
Strategy
Because of limited resources, communicable disease control programmes should focus mainly on diseases that cause the highest morbidity and mortality. During the acute emergency phase, the priorities of the disease control programme might be limited to addressing basic food, water and shelter needs, carrying out surveillance for the top three or five diseases and providing basic treatment for acute illnesses. If possible, the data should be disaggregated by gender and age (simply below five and above five years of age). Once the emergency phase is over, an in-depth assessment should be carried out. In disaster prone areas, it is important to realise that interventions do not start from scratch. Some control measures might have existed before the disaster and responders must capitalise on that. For example, there are often local government officials, volunteers and local or international agencies on the ground that can together bring some experience with local disease prevention as well as preparedness efforts. However, these local services are often not adequate for controlling a sudden increase in common diseases especially epidemics. External support is nearly always needed and if there is evidence of increasing problems due to other diseases, additional control measures might be considered.
Define the goals, objectives and strategies for disease control
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However, carrying out additional control measures should be coordinated with the government, the Inter-Agency Standing Committee health cluster or the agreed coordinating body, to make best use of resources and the future plans for the assisted population. The following table summarises examples of disease control strategies for the acute and post-emergency phase.
Table 7-3: Examples of disease control strategies for emergencies
Communicable disease control strategies
Before outbreaks or epidemics Preparedness Agree on who is in charge, roles and responsibilities; Establish Plan of Action for tackling the and outbreak; Measles (vaccines, syringes, surveillance); Volunteers, peripheral health staff, outreach workers trained and prepared; Put surveillance system in place using communities and volunteers specifically; Assess and map clinics, operational status, capacity; Map water sources, food stalls, restaurants, sanitation, slaughter houses and transport routes in and out of the area(s); Availability of essential drugs and Inter Agency Emergency Health Kits for Acute Watery Diarrhoea/Cholera (ORS, Chlorine, training of volunteers, awareness, Cholera kits available); Acute Respiratory Infections (ARIs) (tents, shelter available; Tetanus (TT, sera available); Malaria (nets, sprays, RDT material, correct drugs available); Reproductive Health (Minimal Initial Service Package (MISP) Kits available); Referral system established Health care staff trained;
Action plan during outbreaks Confirm who is in charge, roles and responsibilities; Limit the spread, take precaution in neighbouring areas, check transports in and out, and implement the Before outbreaks or epidemics scheme in those areas; Further train and use volunteers to detect cases; Further train volunteers in community awareness and in vaccination campaigns; How to enhance existing basic health care services, how the health information system should be managed; Sanitation ( hygiene promotion, latrines, waste management ); Safe and sufficient water supply; Provision of soap; Adequate food and nutrition; Adequate Shelter; Basic health care and referral of emergencies; Safe mother hood and safe deliveries; Immunisation for measles;
Preparedness
Establish functioning sanitation system and safe and sufficient water supply; Undertake appropriate vector control; Provision of soap; Ensure adequate food and nutrition; Protection from environment (Shelter); Basic health care and referral of emergencies; Health education on Reproductive Health (especially STDs and HIV); Monitor for Gender Based Sexual Violence (GBSV); Immunisation for measles (< 5s). Continue Prevention, including among host population or neighbouring areas: Clinical diagnosis; Basic diagnostic capacity with Rapid Diagnostic Tests (RDTs) or microscopy; Use referral laboratory *; Use Inter Agency Emergency Health Kits (IEHK) basic modules for peripheral basic care and complementary for Health Centres and Hospitals. Monitor illness and death due to: Most common diseases (ARIs, diarrhoea measles, malaria, in MCH); Health information systems capable of providing early detection of epidemics like Acute Watery Diarrhoea/cholera, malaria, meningitis.
Expand immunisation efforts (measles for < 15 years, meningitis for certain areas); More aggressive vector control e.g. IRS (Indoor Residual Spraying); TB treatment under special conditions; Meningitis immunisation under certain conditions; Prophylaxis (e.g. cholera, malaria).
Containment and case management
Establish Contingency plans; Diagnostic and treatment algorithms, e.g., IMCI** ; On-site laboratory for malaria smear, stool ova/cyst, haemoglobin, gram stain, sputum smear, blood sugar, HIV test. (blood typing and transfusions also possible); Essential drugs and supplies (stratified for different levels). Monitor illness and death due to: Most common diseases; Skin and eye infections; Urinary tract infections and sexually transmitted diseases (STDs); Parasitic infections; TB, HIV; Malnutrition and micronutrient deficiencies; Pregnancy and childbirth and other reproductive health problems. Experiences of all parties and at all levels to discuss improvement; In-depth evaluations.
Surveillance
Lessons learnt, building better systems for future
Constant monitoring, reviews and evaluations.
* An on-site laboratory may be set up in the acute phase if there is a major disease outbreak or high drug-resistance (malaria, dysentery) ** Integrated Management of Childhood Illnesses (IMCI)
Before outbreaks or epidemics
Action plan during outbreaks
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Develop a plan of action
During the first phase, a couple of days or one week, action based on the available data and information, which often is incomplete or probably inaccurate, must be taken. Major decisions have to be made on a daily basis under these conditions and, essentially from the humanitarian assistance efficacy point of view, it is better to be >50% right than being completely wrong i.e. waiting for decisions because there is no data. Such decisions have to be combined with how disease patterns have developed in similar past situations. Despite a very high workload in this intensive period, a plan of action prioritising actions in areas of concern and a plan for key interventions for controlling diseases that are likely to cause high morbidity and mortality must be started. An example of a plan of action is shown below:
Table 7-4: Example of a plan of action for prevention and control of common diseases
Disease Target group Confirma tion Prepared ness Outbreak control/ prevention Treatment Common errors
Acute Watery Diarrhoea (AWD)
Young children
History/ physical examinati on
Obtain ORS Train volunteers, staff Raise community awareness about serious signs etc Create awareness, obtain antibiotics, train staff handling and referral of severe cases
Improve sanitation and hygiene ORS widely available
Rehydration Knowledge how and when to use Oral Rehydration Salts (ORS) or Therapy (ORT) Antibiotics
Over emphasis on IV fluids Scepticism on ORS It is not a DRUG Belief that antibiotics are needed Seeking medical care/ doctor too late Limited access to clinic Not affordable Waiting for outbreak to occur
Acute Respiratory Infections (ARIs)
Young children
History/ physical examinati on
Improve shelter conditions
Measles
Young children
Diagnosis by experienc ed health worker Blood smear, Rapid diagnostic tests (dip sticks) Stool culture, diagnostic sticks
Vaccination, how to trace contacts
Mass immunisation campaign* Vitamin A Mosquito control, nets and spray
Treat cases, supplementa ry feeding
Malaria
(Falciparum, vivax)
Young children, pregnant women and all nonimmunes AWD mainly affects children, cholera affects also adults
Surveillance, understand disease pattern Procure diagnostics and treatment Surveillance Procure ORS,IV fluids & chlorine
Effective anti-malarial drugs
No surveillance, failure to confirm illness
AWD/ Cholera*
Improve sanitation, water supply, hygiene
ORS, antibiotics*
Seeking medical treatment late Delayed confirmation of cholera outbreak
* Might be carried out too late. *2 Note: Cholera confirmation can be very elusive, and that for various reasons. Competent laboratory may be not easily available, and sometimes, the government is reluctant to declare a cholera outbreak, which may have serious implications on tourism,
*3 Antibiotics have little proven value, except in reducing the number of days of diarrhoea and the severity. Communicable diseases do not discriminate between the displaced and host populations, therefore, national health authorities must be involved in planning and implementing the communicable disease control programme. The following areas should be agreed upon: Linking the disease control programme for displaced people with the national programme; Common treatment protocols to be used; Coverage of the local population in the communicable disease control programme; How and when to refer seriously ill people to local or temporary field hospitals; If possible, use host country referral laboratories, mission hospitals or others reference laboratories outside the country; Supply of essential drugs and laboratory re-agents for health facilities of the displaced and also the local population; What to do with already diagnosed chronic diseases. Refer them if possible. Do not start up treatment, if the patient cannot continue after the emergency care is terminated; How to follow-up on displaced persons with chronic diseases after repatriation; Disease surveillance and programme evaluation.
Estimate resource needs

A communicable disease control programme might require a significant amount of resources including infrastructure (e.g. special treatment centres), drugs and medical supplies, staff (for surveillance, health care and disease control), laboratory equipment and supplies, diagnostic and treatment guidelines, stationery, and transport. PreventionRaising community awareness and mobilizing them to undertake simple preventive measures like personal hygiene, using bed nets if available and how to recognise and refer suspected cases. This calls for prior training of volunteers to detect suspected cases, report and initiate basic acre and sometimes to provide basic treatment (such as Oral Rehydration Salts (ORS); Emergency treatment centres Special treatment centres, e.g., ORS corners, cholera treatment centres, TB manyattas (huts) and Shigella centres might be needed to improve treatment and limit the spread of diseases by infected persons. If the capacity of existing facilities is too little, temporary facilities equipped with adequate staff and supplies can be established in huts, school buildings or tents. The communities, health workers and caregivers should have facilities for hand-washing and also for disposing of excreta or other human waste; Trained manpower is often a major obstacle to deliver even basic care. Hiring locally available doctors and nurses simply depletes the local health care system of its most valuable asset in other localities. To estimate specific staffing needs, please refer to the Sphere Standards; Drugs and medical supplies When selecting drugs and medical supplies, consider the host country treatment protocols. If not available, use WHOs recommended treatment regimens. WHOs guidelines or essential drug list defines the specific
Angola cholera outbreak June 2006- Barrels of chlorine were distributed to cholera treatment centres. Photo: Tapiwa Gomo/International
Federation
business etc. Any AWD outbreak with mortality amongst adults must be considered as highly suspicious for cholera and action should be taken accordingly, even before cholera confirmation has been received.
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drug dosages and patient treatment categories for the priority diseases. The amount of drugs and medical supplies needed might be estimated as follows: Calculate the drug requirement per patient for each disease; Estimate the number of expected cases, based on the assessment data; Estimate the number of expected patients in each category; Avoid syrups and injectables as much as possible because they can cause great logistical problems; Calculate the total drug requirements; For tablets that can be broken add 10% for children and for possible waste; Add 50% for reserve stock.
Note: It is important to assess possibilities for safe local procurement of drugsin the
quantities and quality that is requiredand if not possible, what is needed to import. Advance procurement of Interagency Emergency Health Kits (IEHKs) for starting up emergency operations saves time. They are prepared and ready for dispatch and kept by many suppliers in Europe. Note: When importing drugs or accepting donations, the Interagency Guidelines for Drug donations should be followed. According to these guidelines, only drugs that are registered in the country of operations can be imported. Note: Pre-packaged drug kits have been developed that might be used during the initial phase. If patients see that the drugs are effective, other patients might be encouraged to get treatment. IEHK is designed to treat 10,000 persons with common illnesses during the first three months of an emergency situation. It consists of ten basic units and a supplementary unit. (See the health system chapter for more details on the IEHK). The basic units can be ordered separately and used by people with no training in health. Note: Host government employees, i.e. doctors, have different prescription habits, often practice multi-pharmaceutical approaches: e.g. often two or more antibiotics are prescribed for an infection and preferably, of the latest fashionand expensive. Such practices rapidly deplete stocks and financial resources.
Define standards and indicators for monitoring the programme

Setting standards of performance is essential to ensure that the disease control interventions are appropriate and of acceptable quality. Some host governments might have some standards or they might have adopted WHO standards or supporting NonGovernmental Organisations (NGOs). The Sphere Project Minimum Standards for all sectors might also be applied for the planning and evaluation of communicable disease control programmes where there are inappropriate or no standards. Progress in achieving standards in one sector often influences and even determines progress in other sectors. The disaster-affected communities participation in the selection, implementation, monitoring and evaluation of standards for communicable disease control is essential. The following table defines the recommended minimum standards for the prevention and control of communicable disease threats during natural disasters and complex emergency settings.
Table 7-5: Minimum standards for communicable disease prevention and control33 Intervention Shelter and site planning Minimum standards Existing shelter and settlement solutions are prioritised via the return of hosting of disaster affected households and the security, health, safety and well-being of the affected population are ensured. All people have safe and equitable access to sufficient quantity of water for drinking, cooking and personal and domestic hygiene. People have adequate numbers of toilets, sufficiently close to their dwellings to allow them rapid, safe and acceptable access at all times of the day and night; Each disaster-affected household has access to sufficient soap and other items to ensure personal hygiene, health, dignity and well-being. Food safety People have access to adequate and appropriate food and non-food items that ensures their survival, prevents erosion of assets and upholds their dignity; Food is stored, prepared and consumed in an appropriate manner at both the household and community levels; Moderate and severe malnutrition is addressed. Health education People have access to information and services that are designed to prevent the communicable diseases that contribute most significantly to excess morbidity and mortality. All people have access to health services that are prioritised to address the main causes of excess mortality and morbidity; People have access to clinical services that are standardised and follow accepted protocols and guidelines; All children aged 6 months to 15 years have immunity against measles. Vector control All disaster affected people have the knowledge and means to protect themselves from disease and nuisance vectors that are likely to represent a significant risk to health and well-being; Number of disease vectors that pose a risk to peoples health and nuisance vectors that pose a risk to peoples wellbeing are kept to an acceptable level; Note: this includes intermediate hosts like foxes, sheep, rats and others that promote spread of many diseases including viral hemorrhagic fevers, plague, etc. Malaria, trypanosomiasis, leishmaniasis, dengue, yellow fever, typhus, chikungunya, Japanese encephalitis Diarrhoeal diseases, malaria, Sexually Transmitted Infections (STIs), TB, HIV All diseases Top killer diseases since malnutrition increases risk of disease Target diseases Diarrhoeal diseases, ARI, meningitis, TB, HIV
Water supply
Diarrhoeal diseases, typhoid, scabies Diarrhoeal diseases, polio
Sanitation and hygiene
Health services
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Intervention
Minimum standards People have an environment that is acceptable, uncontaminated by solid waste, including medical waste, and have the means to dispose their domestic waste conveniently and effectively; People have an environment in which health and other risks posed by water erosion and standing water including storm water, floodwater, domestic wastewater and wastewater from medical facilities are minimised.
Target diseases Malaria, dengue, yellow fever
Environmental control
Epidemic preparedness and response
Measures are taken to prepare for and respond to outbreaks of infectious diseases; Outbreaks of communicable diseases are detected, investigated and controlled in a timely and effective manner.
All diseases
It is important to identify a few indicators to monitor the progress and outcomes of disease control efforts. Collecting data for selected indicators should not be difficult. To assess outcome and impact, train field workers accordingly, for example community health workers (CHWs) cannot gather information about change in health seeking behaviour after intensive information, education and communication campaigns without being trained accordingly. The following table illustrates examples of key indicators for monitoring selected disease control activities:
Table 7-6: Key indicators for monitoring disease control activities Defining key process indicators Goal Prevent excess mortality and morbidity from communicable diseases Objective Immunise more than 90% of all children in target group for measles. Input indicator % of volunteers and CHWs trained to promote immunisation; Frequency of vaccine shortage. % of volunteers and CHWs trained in control of diarrhoea; Availability of Oral Rehydration Salt (ORS). Output indicator No. of mothers counselled on immunisation; No. of children that received DPT2. No. of mothers who know how to prepare ORT; No. of rectal swabs examined. Outcome indicator % Children fully immunized Incidence of measles cases Measles mortality rate % of diarrhoea cases given ORT. No. of admissions due to severe diarrhoea. Percentage of deaths due to diarrhoea
Reduce deaths from diarrhoea to pre-disaster levels in 3 months.
Goal
Objective Reduce prevalence of malaria, TB and HIV to host country levels in 6 months.
Input indicator % of volunteers, CHWs and Health workers trained in disease control according to national standards; % of households that received bednets; % of children < five years that slept under a bed net; No. of health facilities providing malaria, TB and HIV counselling and treatment services
Output indicator % of population aware about HIV/AIDS; No. of children given antimalarial treatment within 24 hours of onset of symptoms; Case detection rate.
Outcome indicator % of youth that delay first sexual encounter Prevalence of malaria TB treatment success rate
To guide decision-making, it is important to disaggregate all morbidity and mortality data by age (initially for under five and above five years) as well as by gender. All data should be kept safe and only shared with those who have a stake in service delivery and programme management. (For more details on data analysis and reporting, see the Epidemiology chapter. The last section for this chapter on Monitoring, Evaluation and Operations Research describes more indicators (with examples of malaria, TB and HIV indicators).
Prevention, surveillance, preparedness and response

This section uses a systematic approach to review disease control strategies for prevention, surveillance, emergency preparedness, outbreak investigation and response, case management and control of communicable diseases.
Prevention
The most effective means for reducing a disease burden is through preventive strategies. The goal of prevention is to preserve the health of displaced persons by prevention outbreakspredicting and lessening the impact of any possible outbreak of disease. Preventive measures focus on the initial stages of the communicable disease cycle, namely risk and exposure factors and susceptibility to the disease, as follows: Prevent the development of infectious agents that can attack susceptible individuals Since this may be difficult, minimize the multiplication of infectious agent, e.g., by chlorinating water, disposing of human faeces properly, and draining wastewater; Minimise opportunities for exposure to infections interrupt disease transmission by distributing bednets, treating or isolating infected persons and improving water sources and shelters; Reduce susceptibility to infectious diseases improve a populations immunity by promoting better nutrition, immunisation, and others means of self-protection.
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Community leaders, community volunteers and community health workers can play a critical role in planning and carrying out preventive strategies such as health education and sanitation, thereby ensuring positive behaviour change e.g. malaria bed nets are properly used. Active and well respected members of the affected community can be recruited and trained as volunteers in health education as they share the same language and culture as the target population. They can provide valuable insight on the community perspectives about specific diseases including the local terms for the cause, symptoms and treatment, and thereby make health education messages more effective. Initially the most educated or visible community members will be recruited. It is important to ensure that all sub-groups are represented including women and minority ethnic groups.
Surveillance
Surveillance is defined as the ongoing systematic collection, analysis, and interpretation of health data, which is essential to the planning, implementation, and evaluation of public health practice. It includes timely dissemination of data to those who need to know. The final link in the surveillance chain is the application of these data to disease prevention and control. Good surveillance is vital for successful control of communicable diseases. It is not enough to achieve a high coverage of bed net distribution, chlorination of water and other disease control measures. Without collecting and analysing health data such as disease incidence, health workers would not be able to detect outbreaks and alert people early or identify groups at increased risk of death from communicable diseases. Good surveillance can increase understanding about the changing disease patterns as well as guide disease control measures. During natural disasters and complex emergencies, a surveillance system needs to be set up as soon as possible. It should focus on diseases that cause the most problems, which can be controlled by local measures. Where possible, the emergency surveillance system must be linked with the host countrys surveillance system. The facility-based health information system should be augmented with a community based surveillance that uses volunteers and Community health workers or health information teams to gather essential data through home visits and other means. The figure below gives an example of functioning community based surveillance system.
Figure 7:3: Example of effective community-based surveillance From October to December 1997, El-Nino rains caused widespread flooding in North Eastern Kenya. Over 20,000 people were displaced and required assistance from local NGOs in Garissa. People who became ill pursued health care from private practitioners. To increase access to basic health care for the displaced communities, the Kenya Red Cross Society set up a basic health facility which included a cholera treatment centre. 100 Community Health Workers (CHW) were trained to make daily home visits, identify and refer all individuals with signs and symptoms of diarrhoea or other acute illnesses to the Red Cross health facility. In addition, the CHWs visited private health practitioners to inform them about the cholera centre and gave them referral and reporting forms in order to capture all suspected diarrhoea cases. Within three days CHWs identified seven local persons having bleeding from the nose, mouth, urine and stool. Police reports identified thirty-two similar cases in surrounding districts. The Red Cross team subsequently assisted researchers from the ministry of health, the WHO, Centres for Disease Control and elsewhere to perform the initial investigation that revealed there was an outbreak of Rift Valley fever. Further enquiry revealed that most affected families owned livestock that became ill or had died during the floods. Through daily visits to homes and private practitioners, CHWs proved very effective in early identification of suspected cases of haemorrhagic fever cases and cholera, referring all suspects to the Red Cross health facility for clinical management as well as in educating affected families about prevention of haemorrhagic fever and cholera. Source: Johns Hopkins University
Surveillance forms
Such a system needs to record all deaths occurring at health facilities and within and outside settlements. For morbidity information, only newly diagnosed cases should be tallied under the specified disease condition. Patients returning to health facilities for the same health problem within a certain period (e.g. seven days) might be recorded as revisit cases. Depending on the reporting frequency, this information can be summarised on mortality and morbidity surveillance forms daily in the early phase of an operation, then weekly, or monthly. Unfortunately in real disasters, this is a problem mortality figures often do not stabilise until after two to three weeks. Patients might also visit more than one health facility for more effective treatment. See the appendix for examples of surveillance forms. Sources of data Surveillance data may be collected from the following sources of information: Morbidity and mortality reports from health facilities and community health workers. However, one can only monitor the trend for these indicators because many health facilities in developing countries keep poor records. By the end of the month, a few facilities might be tempted to fabricate some plausible figures. It is therefore critical to be very cautious with facility record reviews and interpretation of findings; For the post-emergency phase and long-standing relief programmes, reported deaths from central death registers, health workers, community leaders, etc.; Laboratory reports on isolation and identification of infectious agents; Reports on water supply, sanitation, vector control, shelter, food distribution, etc. from health-related services; Rumours or reports of disease outbreaks from community leaders, schoolteachers, volunteers, field supervisors, etc. Standard case definitions These are criteria that help health workers decide if a person has a particular disease or health problem. In emergencies, all operational agencies have to agree to use only one set of case definitions Case definitions may be classified according to different criteria, including the following: Site of clinical disease upper or lower respiratory infections; Severity of disease uncomplicated or severe malaria; Laboratory results suspected or confirmed meningitis; History of treatment new, relapse, treatment failure or treatment after interruption case for tuberculosis. Standard case definitions for common health conditions are often needed for the following: Registration of cases Standard case definitions are used to diagnose and record common health problems affecting the population. This helps to accurately monitor the disease trends and make better estimates of required resources, e.g. malaria, pneumonia. If standard case definitions are used at several locations or by different relief agencies, disease trends among different populations can be compared; Notification Standard case definitions are used to alert national health authorities about outbreaks of notifiable diseases, for which regular and timely information on individual cases is necessary for the prevention and control of
The host country always has a Health Information System (HIS). There are forms to be filled and reports filed regularly. One should follow the host country protocols. But many national HISs are weak and not quite reliable. Some agencies need to set up their own surveillance system. This is acceptable provided HIS conforms to the ministry of health approach and the initiative is coordinated with other agencies and the Inter-Agency Standing Committee health cluster.
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diseases). These include measles, cholera, shigellosis, meningitis, hepatitis, TB, yellow fever, HIV/AIDS, and haemorrhagic fever; Appropriate treatmentPatient treatment might be prescribed according to standard case definitions, e.g. Acute Respiratory Infection, TB. Standard Treatment Protocols defines the most effective way of treating a certain disease in a specific country. They are essentially based on the WHO standard protocols. They are not always followed by local doctors, but international aid agencies must comply with the official MOH version. In emergencies, it is often remarkably hard to get hold of such protocols; until further clarification, the WHO protocols must be used. The challenge often is to have all organisations to agree on one set of treatment protocols, usually discussed and established during coordination meetings. Most case definitions in the remaining chapter are based on clinical and epidemiological information. This is because health worker skills might be limited. Laboratory confirmation and access to x-ray facilities might also not be practical particularly in the acute emergency phase. . Epidemic thresholds are the minimum number of cases indicating the beginning of a particular diseases outbreak. Although many risk factors might indicate a possible outbreak, it is difficult to predict when and where the outbreak will actually begin because clear case definitions and thresholds have not been defined for all communicable diseases. Specific and non-specific epidemic thresholds have been defined for the following diseases: Specific: a single reported case can imply an outbreak for the following diseases: measles, cholera, Shigella, yellow fever and viral hemorrhagic fever; Meningitis: The following table provides thresholds for predicting meningitis outbreaks among different settings:
Table 7-17: Threshold for predicting meningitis epidemics in different settings
Setting Threshold
Area endemic for meningitis (with populations of 30,000100,000). Area where meningitis epidemics are unusual, outside the meningitis belt. (Also where population data is not known, refugee or closed communities). A settlement next to an area where an epidemic has been declared.
Fifteen cases per 100,000 persons per week in a given area, averaged over two consecutive weeks. Increasing proportion of patients five years or older, primarily among school children and young adults. Three-to four-fold increase in cases compared with a similar time period in previous years. Doubling of meningitis cases from one week to the next for a period of three weeks.
Five cases per 100,000 persons per week.

Source: WHO
Non-specific threshold: there is no specific threshold level to define malaria outbreaks. An increased above the expected number of cases for a particular population at a specified time of year in a defined location may indicate an outbreak. Case definitions and epidemic thresholds for diseases that can cause outbreaks in a particular emergency setting must be distributed to all reporting health facilities otherwise, an outbreak might become large scale simply because the surveillance team failed to recognise and respond to it in time. Building local capacity to track weekly incidence rates and compare them to the previous months or seasons might improve the
Once an outbreak of a notifiable disease is detected, it must be reported immediately to all concerned. In resource limited settings, only a certain number of the initially reported suspected cases must be confirmed (by laboratory, where possible). Thereafter, all suspected cases may be considered as a true case and given the appropriate treatment and follow-up. For more specific case definitions, please see the appendix at the end of this chapter.
Emergency preparedness
Many factors can cause failure in disease prevention and lead to disease outbreaks, including: A lack of political commitment and funding; Poor surveillance systems; Non engagement of the community; Poor organisation of health care services; Lack of resources to fulfil the required task, especially at peripheral level; Too few trained staff, especially at the peripheral level; Insufficiently trained health care staff, or inadequately updated in their knowledge; Inadequate or incomplete treatment of cases; Over-reliance on preventive measures, e.g., water chlorination, immunisations, etc. The following box presents all measures that must be taken to ensure adequate preparation for any disease outbreak according to the Sphere Standards.
Figure 7-4: Outbreak preparedness standards for Sphere Project
1. An outbreak investigation and control plan must be prepared. 2. Protocols for investigation and control of common outbreaks are available and distributed to relevant staff. 3. Staff trained on the principles of outbreak investigation and control, including relevant treatment protocols. 4. Reserve stocks of essential drugs, medical supplies, vaccines and basic protection material are available and can be procured rapidly. 5. Sources of vaccines for relevant outbreaks (e.g. measles, meningococcal meningitis, yellow fever) are identified for rapid procurement and use. Mechanisms for rapid procurement must be established. 6. Sites for the isolation and treatment of infectious patients are identified in advance, e.g. cholera treatment centres. 7. A laboratory is identified, whether locally, regionally, nationally or in another country, that can provide confirmation of diagnoses. Sampling materials and transport media for the infectious agents most likely to cause a sudden outbreak are available on-site, to permit transfer of specimens to an appropriate laboratory. In addition, several rapid tests may be stored on-site.
prediction of an outbreak. Another option by which to determine whether reported cases are sporadic or suggest an epidemic is to compare the disease incidence rate or attack rate (the proportion of those exposed to an infectious agent who become clinically ill) to the epidemic threshold.
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Outbreak investigation, response and containment
Once rumours or reports from the community or other sources of a possible disease outbreak are received, initiate proper investigation and control measures as soon as possible. Form outbreak response committee needs at various levels to co-ordinate all activities. Include in the committee representatives from the affected community, health facilities, disease surveillance and control units, reference laboratory and sometimes staff from the livestock and veterinary sectors. At the regional and central levels, the Ministry of Health (MoH) is normally the dedicated coordinator in such situations supported by organisations and the Inter-Agency Standing Committee (IASC) cluster. Occasionally especially when the MoH has weak leadership capacity, another agency or the IASC health cluster can be temporarily named as the lead agency. Objectives for investigating a possible outbreak may include the following: To confirm and establish the extent of the disease outbreak; To identify the cause(s) and ways of preventing further transmission of the disease; To define the best means of dealing with the outbreak; To determine ways of preventing future outbreaks. The investigation needs to be undertaken in a systematic way, as described below.
Confirm the epidemic

The first report of a communicable disease outbreak should be confirmed whether or not an epidemic really existsor dispel the rumourand broadly describe to the affected population approximately how many cases have been identified etc. Subsequently, the investigation team can concentrate on a more elaborate report. False epidemics might be the result of changes in data collection and reporting, new treatments being introduced, improved access to health facilities etc. The existing surveillance system can be revised, if n, to detect all new cases. Compare the incidence of the disease with previous seasons to check if the number of cases exceeds the expected level.
Verify the diagnosis

Standard clinical or laboratory methods should be used to diagnose the outbreaks cause. An interim diagnosis, e.g. cholera or food poisoning, might initially be used to identify the type of resources needed for the investigation.
Identify the affected persons and their characteristics

Establish a standard case definition for identifying all possible cases. Collect and record the clinical history of the index case(s) and describe the outbreak in terms of time, place and person. Reviewing the age and gender distribution, immunisation status, and other characteristics will help identify those at greatest risk. Mapping the location of each case will help identify clusters of patients and a common source of infection. These maps should be used to plan and co-ordinate control measures.
Define and investigate the population at risk

From the collected information, calculate the attack rate and graph the number of reported new cases per day or week. An epidemic curve can bring to light the epidemics onset and magnitude, its incubation period and how the disease is spreading (single source, multiple sources etc.). Two to three weeks after disasters, the risk for outbreaks of Acute Watery Diarrhoea/Cholera, Acute Respiratory Infection, malaria, dengue, tetanus are high. The prevention and preparedness should be designed accordingly.
Figure 7-5: Example of epidemic curve
20 15
20
10
New cases 10 5 0 1 2 3 Week 4 5 6
6 2 1 3
Possible nidus
Basically there are four mechanisms for disease transmission; droplets in air, faecal-oral, vector and contacts. Poverty and vulnerable groups are other elements related to population characteristics. The affected community should be mapped accordingly; identify cramped quarters, the status of water supply and sanitation system situation, food stalls/restaurants, markets and vectors.
Formulate a hypothesis about the source and spread of the epidemic

To explain why, when, and how the epidemic occurred, the situation or conditions before the outbreak must be understood. Understanding the epidemiology of communicable diseases might help to identify the cause of the outbreak (refer back to Table 7-8).
Verify the causative disease agent and the mode of spread

The probable cause of the outbreak must be identified in order to select more effective control measures. A case-control or other type of study must be carried out to test theories about the disease agent and mode of spread. Laboratory investigations must also be conducted for affected cases and contacts, where possible. Environmental sampling with laboratory analysis might be done to confirm a suspected source of infection.
Control the epidemic

Control of communicable disease outbreaks focuses on containing the spread by protecting susceptible persons while managing the more advanced stages of the communicable disease cycle, namely the biological evidence of infection, clinical illness and progression of disease in infected persons. Possible outbreak control measures must emphasise the prevention of a disease outbreak. Once there is an outbreak, measures should include the following: Primary prevention against the development of biological and clinical signs of disease by immunising susceptible people, appropriate site planning, provision of safe and adequate water, practising good sanitation, protecting food stores, markets, restaurants, implementing vector control etc.; Secondary prevention preventing mild illness from becoming more serious by diagnosing early and treating with antibiotics (where appropriate) and supportive care. against mild illnesses becoming more serious by diagnosing early and treating with antibiotics (where appropriate) and supportive care; Tertiary prevention against disease complications by referring or treating individuals with cerebral malaria, children with severe TB and malnutrition, etc.
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Case management
Effective case management requires health services to be accessible to all high risk groups (which could be the entire population). Most people affected by an outbreak do not seek health care from available health facilitiesit is a well-known fact that most children die before they reach the clinic. Much of the case management takes place in the community. This makes it absolutely vital to engage communities and its volunteers to raise awareness and ensure that serious cases are sent to the clinic. In areas where laboratory facilities are lacking, diagnostic sticks, clinical and symptom-based diagnosis for communicable diseases remain the standard for case management. Simple diagnostic algorithms and treatment protocols can be developed or adapted for the local situation by the local health authorities and other partners involved with health care delivery. The standard treatment protocols of the host country as well as of refugees countries of origin must be considered. In addition to being simple and straightforward, treatment regimens for communicable diseases must be based on sound evidence that is applicable to most settings. The following criteria can be considered: availability, efficacy, affordability, tolerability and the benefit to the majority of people and options for second line treatment. This approach will help simplify the: Procurement and drug logistics management; Treatment protocols with options for clinicians; Stand by treatments, single dose treatments are of particular importance in emergencies; Distribution at peripheral level/ in communities of certain drugs (such as ORS); Sequencing of treatment; and Preservation of low cost drug regimens at a population level and minimizing the risk of drug resistance. Single or Fixed Dose Combinations (FDCs) are preferable for the standardised regimen: they are easier to administer and monitor because of their reducing of the pill burden and thereby increase adherence to treatment. However, FDCs with appropriate dosages for children are less available. It is likely that more FDCs will be available in the future. As well as training and mentoring health care providers about standard treatment guidelines, distribute copies of treatment protocols to all treatment facilities. In postemergency settings, traditional healers and private health practitioners at local shops and pharmacies might prescribe inappropriate treatment for communicable diseases or provide inappropriate patient education. Training about these protocols must be strict. Because traditional healers and private health practitioners cannot be stopped from practicing, it is, therefore, better to improve their skills. The amount of drugs issued via the commercial sector must also be monitored to ensure they are affordable and dispensed with appropriate patient education on use.
Write a report
Regularly document and disseminate progress reports to all concerned about the outbreak investigation and response. In early stages, reports must be daily. Once the operation and situation has stabilised, less frequent reporting can be agreed upon also making them more comprehensive and covering more diseases. Today, filing a report on time is not a problem. It is easy to e-mail, but in many disasters, the Internet can be unavailable. Therefore, one must be able to send messages by SMS or satellite telephone ensuring that the information is reaching its appropriate destination. The affected community must be aware of the nature of the outbreak and how they can protect themselves or assist affected people. Local health authorities need the information to plan appropriate control measures and ensure they are better prepared for future outbreaks. Reports in the media and medical journals might increase external support and improve responses to future outbreaks. In addition to the threat of all possible disease epidemics and local capacity to
Handling the remains of the dead

Although dead bodies do not represent a major health hazard if buried or burned immediately, burying the dead must be planned when any epidemic results in high case fatality. The table below defines basic principles for managing dead bodies after communicable disease epidemics.
Figure 7-6: Principles for management of dead bodies23
1. 2. 3. 4.
Every effort should be made to identify the bodies. Burial is preferable to cremation in mass casualty incidents. Mass burial should be avoided if possible. Families should have the opportunity to conduct culturally appropriate funerals and burials. 5. Where existing graveyards or crematoria are inadequate, provide other locations or facilities. 6. For workers routinely handling dead bodies, promote the following: Universal precautions for blood and body fluids; Use of correct disposal of gloves; Use of body bags if available; washing with soap after handling bodies and before eating; Disinfection of vehicles and equipment; Bodies do not need disinfection before washing (unless cases of cholera, hemorrhagic fever); Bottom of any grave is > 1.5 m above the water table and 0.7 m unsaturated zone.
Scaling up and scaling down disease control efforts

When designing a disease control programme it is important to plan for possible expansion and an exit strategy as discussed below.
Expansion
Possible reasons for scaling up a disease control programme include population influx and movement, stabilization of the emergency situation, and evidence of increased disease burden, disruption of neighbouring health services, more funding support and improved security. Expansion should be gradual to allow for appropriate planning with involvement of the beneficiary population, effective training of staff, procurement of additional supplies and positioning of higher level supervisors to assist as trainers. Training should include volunteers and CHWs in the community, the health staff at
manage the current situation, reports on disease outbreaks need to capture the following indicators: Morbidity: incidence rate, age and sex-specific incidence rates; Mortality: crude mortality rate, under-five mortality rate, case fatality rate. If the Case Fatality Rate (CFR) for a specific disease exceeds what is expected, an immediate evaluation of current disease control efforts should be undertaken. This will encourage corrective measures to be identified that could reduce the CFR to acceptable levels. In general, disease control planners should aim for a CFR as low as possible although for some outbreaks it might exceed 20%. (See the disaster epidemiology chapter for more details about investigating and reporting outbreaks).
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peripheral health facilities that may represent the frontline workers for case-finding and treatment. Laboratory staff also needs training before expanding services.
Contingency planning
In any emergency operation, a contingency plan must be designed for a sudden change of the situation. New population movements, security, new flooding and serious earthquake aftershocks may dramatically change the scene. In most operations, this element is sorely neglected and when the agencies are often taken by surprise.
Phasing down or out

Every emergency programme needs to include a contingency plan for probable phase down or closure. Possible reasons include unstable situations in the area within the camp, forced relocation of the refugees, decreased donor support or declining disease burden. While many disease control programmes may be terminated quite rapidly (e.g. within 1 month), scaling down of TB control needs to be stretched over a period of not less than 3 months. Although no new cases would be enrolled, a gradual phase down would allow for existing TB patients to either complete their regimens or to establish appropriate linkages and follow-up at their next destination.
Community participation in communicable disease control

Communicable disease control in emergency and post-emergency phases is delivered effectively when it is participatory. Experience and many studies document the benefits of using a community participatory approach to relief in emergency settings and to development in post-emergency phases. The benefits are many. Participatory relief programmes can deliver aid in a timely manner, ensure that resources reach the most vulnerable and poorest individuals, enhance rather than weaken existing health structures and empower communities to take more control of their lives. Yet, while emergency health agencies that implement communicable disease control widely proclaim their commitment to community participation, genuine examples of participation by beneficiaries are rare.25 Although Red Cross and Red Crescent National Societies and few other agencies often work at the community level, many host authorities and affected populations complain about the relative absence of additional community participatory programmes. Some suggest that international aid agencies are inherently inflexible caused by rigid funding structures and accountability to their donors.11 Others argue that aid workers commonly hold superior attitudes and view the poor and affected populations as incapable of making informed decisions about the design and delivery of aid including communicable disease control programmes. Others still suggest that aid agency staff simply do not remain long enough in one area to listen and respond sensitively to the concerns of beneficiaries.10 Before outlining how communities can participate in communicable disease control programmes in emergencies, it is important to describe what is meant by community participation. Community participation has come to be understood by many relief and development practitioners as follows: Community participation is a process in which community people would become involved in both delivery of and decisions about health and health services in order to provide the type of care most appropriate to their own defined needs and circumstances30. This definition is rather vague to allow flexibility in community involvement for various political, economic and cultural contexts. When implementing communicable disease control programmes in emergency and post-emergency phases, community participation might only be present as a few volunteer or community health workers support
Potential areas for community involvement

Multipurpose volunteers are trained worldwide to do both community awareness and mobilisation when needed as well as detecting disease and ailments. The Red Cross and Red Crescent National Societies do this all the time and well over 100 million volunteers are working for the most vulnerable people. Other organisations have the same principle. A particular programme on water and sanitation, called Participatory Hygiene and Sanitation Transformation or PHAST, embraces these principles in full. In emergency settings, these volunteers are invaluable and often crucial for delivering effective relief and epidemic control programmes. As for communicable disease control programme, these volunteers and community members can participate at several levels of activity. By knowing the disease(s) they should look for and make the community aware of, they constitute a formidable early warning system. Furthermore, the approach is information sharing and consultation, decision-making and initiating action.27 Participatory methods for information sharing and consultation include secondary data reviews, direct observation, semi-structured interviews, group interviews, mapping, diagrams, patient narratives, stories, case studies and surveys.8 In the case of communicable disease control, life narratives and semi-structured interviews can be used to gather information about the social and economic barriers to TB treatment in displaced settlements.
Table 7-7: Steps to promote community participation in communicable disease prevention and control
Level of community participation Methods Examples
Information sharing and consultation
Train community volunteers and Community Health Workers to recognise diseases, do prevention work and report cases; Secondary data reviews, semistructured and group interviews, patient narratives, surveys.
Diarrhoeal disease prevention oral rehydration salts (ORS); Malaria, prevention, bed nets; Collect information on social and economic barriers to TB treatment through life narratives and semistructured interviews. Invite community members to participate in meetings of immunization programme managers. Training and salaries for community health workers willing to provide HIV/TB treatment support (see Fig 7-7).
Decision-making
Hold relief co-ordination meetings in the community and invite community representatives. Make the community aware of resources available for potential community-driven activity.
Initiative action
For prevention, organisations should encourage the communities to identify and map the diseases occurring there and also involve them in preventing such disease and outbreaks and in report them.
programmes that are used to deliver directly observed therapy for active TB. However, developing a community health worker programme does not by itself lead to community participation in emergencies. Instead, community participation exists only when community members are actively involved in identifying their own needs and involved in decisions about how to improve their conditions.
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At the decision-making level, agency staff should ask: How can people participate so they are able to influence the decisions taken at every stage of the communicable disease control project? Participatory methods at the decision-making level include inviting community representatives to relief co-ordination meetings, which usually take place at distances far from the site of the emergency. As for communicable disease control, community representatives can be invited to participate in meetings of immunisation programme managers.
Figure 7-7: Participatory methods for HIV treatment in an emergency
Surviving political crisis in Haiti: Participatory methods for HIV treatment in an emergency In the late 1990s, Partners in Health established, with its sister community organization, Zanmi Lasante (ZL), a community-based treatment model for HIV and TB treatment on the central plateaus of rural Haiti. The ZL model, called the HIV Equity Initiative, is a community-based structure that employs nearly 1,000 community health workers, who provide directly observed tuberculosis and antiretroviral treatment, social and economic support for over 2500 HIV and TB-infected patients near their homes in central Haiti. Details of the programme are described elsewhere28, 13. In February 2004, this community-based model of treatment was tested when a coup dtat removed then-President of Haiti, Jean-Bertrand Aristide. In the months leading up to the coup, much of the nations fragile public health system was further disrupted. Due to insecurity, many private and public clinics remain closed throughout February, March and April 2004. However, all six of ZLs clinics remained open during the unrest and only the six expatriate employees were forced to flee. All the Haitian staff, including the community health workers, remained, and almost none of the programs 2500 HIV and TB patients missed a single dose of their medications. This, of course, is important to the health of individuals suffering from acute and chronic infectious diseases. The ZL model demonstrates that community participation is essential in the struggle to provide equitable health care to the worlds poor, particularly in areas experiencing emergencies19. Afterwards, participatory methods can be used at the level of initiating action. A health relief agency helps empower communities by making them aware of the resources that the agency can offer. This information can spark social mobilisation in various ways in order to access resources. Effective measures have been taken in emergency and postemergency contexts to help communities initiate action in communicable disease control. For instance, the NGO, Partners in Health, offered communities in rural Haiti the opportunity to receive home-based delivery of anti-retroviral treatment of HIV. With the help of Partners in Health which included salaries for community health workers, these communities established a decentralised system of HIV treatment delivery after the directly observed therapy model for TB treatment. In 2004, this system withstood a massive political crisis in Haiti (See Figure 7-7). Finally, community involvement can enhance case detection, assisting to identify defaulters and managing the process. Implementing agencies can engage, community leaders, volunteers, traditional healers, traditional birth attendants, and private practitioners in prompt case detection and appropriate treatment. Community health workers and volunteers may be trained to identify cases through routine home visits while traditional healers and private practitioners may be invited for joint ward rounds in primary health care facilities so that patients could benefit from both medical and herbal treatment. Periodic clinical meetings may also be organised to update the non-formal health providers on new treatment protocols and improved referral mechanisms to assure better patient management from the traditional healers and private practitioners to public health facilities. This will improve treatment outcomes and minimise resistance to new therapies.
Disease threats in natural disasters and conflict situations

Although disease epidemics can occur in both emergency and non-emergency situations, outbreaks are more common among conflict-affected populations where they can cause up to two-thirds of all deaths. This is because malnutrition, safe water scarcity, blunt trauma and disrupted health services are more prevalent in conflict situations particularly long-term conflicts. To improve the health of populations affected by natural disasters and conflict situations, humanitarian actors must address the underlying risk factors immediately after they have initiated disease control measures. If two or more epidemics have erupted simultaneously within a community, humanitarian actors should give priority to the disease with the highest burden of illness and death. The following table defines the diseases that are likely to cause outbreaks with corresponding general preventive measures. Diseases appearing in bold font in the table are likely to cause outbreaks in all situations and will be the main focus for the remainder of this chapter.
Table 7-8: Diseases likely to occur during emergency situations
Classification Diseases possible Preventive measures
Air-borne diseases
Acute Respiratory Infections Measles Meningitis Pertussis (whooping cough) Tuberculosis Influenza Amoebae Cholera Diarrhoea Dysentery Poliomyelitis Hepatitis Parasites: round/hook worm Typhoid Malaria Relapsing fever Sleeping sickness Dengue hemorrhagic fever Typhus Yellow fever Chikungunya Dengue Leptospirosis Leishmaniasis Marbug Lassa Fever Ebola
Site planning Adequate nutrition
Water-related diseases
Site planning Safe water Good sanitation Personal hygiene Case management
Vector-borne diseases
Vector control Personal protection Personal hygiene Case management
Major diseases in emergency and nonemergency settings
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Classification
Diseases possible
Preventive measures
Sexually Transmitted Infections (STIs)
Syphilis Chancroid Gonorrhoea Chlamydia HIV Scabies Worms Tetanus
Health education Security Case management
Other diseases
Hygiene Hygiene
Historical evidence shows that the risk of epidemics after a natural disaster is quite low unless surrounding conditions favour the rapid spread of communicable diseases. There is a close association between epidemics and population displacement since outbreaks rarely occur where natural disasters have not resulted in substantial displacement of the local population. The risk of disease outbreaks after floods and tsunamis is greater than for earthquakes, volcanoes, hurricanes and other high-wind natural disasters. Risk of disease spread increases when populations live in a crowded environment, lack access to safe water, latrines and health services, have poor nutritional status or low immunity to vaccine-preventable diseases. The following table lists some epidemics that have been reported in countries affected by major natural disasters and factors that might have contributed to the outbreaks.
Table 7-9: Risk factors and diseases likely to occur in natural disasters and displaced population settings
Natural disaster Transmission Disease Risk factors
Floods
Water-related
Cholera Typhoid Hepatitis A and E Leptospirosis Malaria Dengue
Contaminated water Population displacement Overcrowding Proliferation of rodents Seasonality Changed habitat Disrupted environmental control Changed human behaviour Overcrowding Low baseline immunization coverage Disruption of electricity Contaminated water Population displacement Overcrowding Injuries Crowding Indoor cooking Malnutrition Limited access to health services Changed habitat Disrupted environmental control Changed human behaviour Injuries
Vector borne
Tsunamis
Airborne
Measles ARI Cholera Typhoid Hepatitis E Tetanus ARI
Water-related
Other
High wind disasters
Airborne
Vector borne
Malaria
Other
Tetanus
Natural disaster
Transmission
Disease
Risk factors
Earthquakes
Airborne Water-related Vector borne Other
Measles Coccidiomycosis Hepatitis E Malaria Tetanus
Low baseline immunization coverage Airborne dust from landslides Water scarcity Changed habitat Injuries Low baseline immunization coverage Low baseline immunization coverage Injuries Low baseline immunization coverage Malnutrition Water scarcity
Volcanic eruptions
Airborne Other
Measles Tetanus
Drought
Water-related
Dysentery
Note: Disease outbreaks after floods, tsunamis and hurricanes are better documented than diseases after other natural disasters. Disease control efforts after natural disasters must include mass casualty management in response to the initial traumatic impact as well as ongoing surveillance, the supply of safe water and sanitation, therapeutic and other preventive interventions for long-term survivors.
Managing common epidemic diseases

Acute Respiratory Infections (ARIs)
ARIs are the leading causes of illness in developing countries particularly among children less than five years. About 20% of all deaths in children under 5 years are due to Acute Lower Respiratory Infections (ALRIs - pneumonia, bronchiolitis and bronchitis); 90% of these deaths are due to pneumonia. Early recognition and prompt treatment of pneumonia is life saving.3.35 (WHO sources). Most of them die before they reach peripheral health care services.
Agent
Although many disease pathogens can cause ARIs, bacteria and viruses together account for 75% of all deaths from pneumonia specific disease pathogens for ARIs include: Bacteria Streptococcus pneumoniae, Haemophilus influenza. Viruses measles, respiratory syncitial virus, para-influenza, adenovirus and rhinovirus both of which can invade any part of the respiratory tract.2, 21 After a viral infection, people are susceptible to a secondary infection, often caused by bacteria. The following factors might increase the likelihood of transmission and poor outcome from ARIs: Environment insufficient shelter, indoor air pollution (smoke from cooking fuel and cigarettes), overcrowding, and reduced access to health care. Host age (less than 2 years and above sixty-five years of age), low birth weight, lack of breast-feeding, malnutrition, vitamin A deficiency, incomplete immunisation, and lack of maternal education.
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ARI can affect one or more parts of the respiratory system as follows: Upper respiratory tract nose, pharynx, epiglottis or middle ear. Lower respiratory tract larynx, trachea, bronchi, lungs. As a result, people with ARIs might show a variety of clinical features such as a runny nose, sore throat, cough, difficult breathing or ear problems. Other diseases such as malaria often mimic the symptoms and clinical features of ARIs. However, a few children with coughs might develop acute lower respiratory infections particularly pneumonia (an acute infection of the lungs). Severe pneumonia can lead to death either from lack of oxygen or infection of the bloodstream (called sepsis or septicaemia). The following table summarises the classification of ARIs based on the main symptoms.52
Table 7-10: Clinical presentation of ARIs
Main symptoms Classification of ARI
Cough, difficult or rapid breathing
Ear pain or discharge
Sore throat
No pneumonia Pneumonia Severe pneumonia Very severe disease (severe complications of measles, whooping cough, diphtheria) No ear infection Mastoiditis Acute ear infection Chronic ear infection Streptococcal sore throat Throat abscess
Source: WHO Integrated Management of Childhood Illnesses (IMCI)
The remainder of this chapter will focus on Acute Respiratory Infection that cause high morbidity and death, namely those characterised by a cough or difficult breathing. Most episodes of ARIs in children are self-limiting and not serious. However, some children can develop pneumonia which might become severe and cause death. This is common where caregivers (usually mothers) and primary health care workers fail to recognise the danger signs of pneumonia (which include the inability to drink or breastfeed, convulsions, lethargy or loss of consciousness). Early and correctly identifying and treating the few sick children with pneumonia among many others with milder respiratory infections will greatly reduce deaths in children.
Case management
Because most refugee settings lack X-rays, laboratories or doctors, simple clinical criteria are needed to assess the child, classify the illness and determine the appropriate treatment which includes referral to hospital, antibiotic treatment and care at home. Again, it should be emphasised that many sick children never reach clinics where they can be appropriately treated. The following table summarises the management of ARIs based on Integrated Management of Childhood Illnesses (IMCI) classification of ARIs.48
Table 7-11: Treatment of cough or difficult breathing

Disease Care of children aged 2 months to 5 years
Severe pneumonia or very severe disease Pneumonia
Give first dose of antibiotic. Refer urgently to hospital. Give an appropriate antibiotic for five days. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow-up in two days. If coughing more than thirty days, refer for assessment. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow-up in five days if not improving.
Source: WHO IMCI
No pneumonia: cough or cold
Note: Health workers must assess, classify and treat young infants aged less than two months differently from older children. This is because young infants may have different Acute Respiratory Infections (ARIs) symptoms and they can die very quickly. All young infants with pneumonia must be referred immediately to a hospital.
Control of ARIs
The control of ARIs is based on early detection, early referral and standard case management. Volunteers and Community Health Workers (CHWs) in the community can play a major role in controlling the disease. This also requires staff training, adequate drug supplies and ARIs management charts for Primary Health Clinics (PHC) workers (e.g. IMCI). Access to health care (first-level health facilities and first referral hospitals) should also be assured. In addition to case management, ARIs control also involves health education and promotion. This will ensure that caregivers give appropriate home care, recognise danger signs and know when to seek help. Promoting breast-feeding, immunisation (for measles, whooping cough and diphtheria), vitamin A supplementation and reducing domestic pollution will lead to fewer episodes of ARIs in children.
Diarrhoeal diseases
World Fit for Children target: Reduce by one half deaths due to diarrhoea among children under the age of five. Diarrhoeal diseases account for nearly 2 million deaths a year among children under five, making them the second most common cause of child death worldwide. (UNICEF source). Diarrhoeal diseases cause major health problems among disaster-affected populations. Among displaced populations, diarrhoeal diseases account for over 50% of the deaths during the acute emergency phase. Although many organisms cause diarrhoeal diseases, only Vibrio cholera and Shigella dysenteriae have the potential for causing major outbreaks in emergency situations. In 1994, 85% of the 50,000 deaths that were recorded in the first month after the influx of 800,000 Rwandan refugees into North Kivu in Democratic Republic of the Congo were caused by cholera and Shigella dysentery. Scarcity of water was the most important risk factoran estimated 200mL per person per day was provided to the displaced people in the first week of the crisis. Consequently, between March 2001 and October 2002, 55 cholera epidemics were reported in Democratic Republic of the Congo with 2129 deaths among 38 000 cases from 51 health zones in 7 provinces. The case fatality rate was therefore excessive: 56% (range: 0 337%) (WHO Alert and Response, unpublished data).
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The following table summarises the causative agents for common diarrhoeal diseases:
Table 7-24: Common causes of diarrhoeal diseases

Type Classification Causative agent
Acute Watery Diarrhoea (AWD)
Bacteria
Enterotoxic E. coli, Clostridium perfringens, Staphylococcus, Campylobacter jejuni, Salmonella (non-typhoid). Rotavirus, Enterovirus, Adenovirus.. Vibrio Cholera Candida albicans*. Giardia lamblia. Shigella dysenteriae, Salmonella typhi, Enteroinvasive E. coli, Yersinia enterolitica. Entamoeba histolytica.
Viruses Vibrio Fungi Parasites Bloody Diarrhoea Bacteria Parasites
* Usually affect people with lowered immunity. Note: Cholera and dysentery are not the most common causes of diarrhoea except during epidemics. Most cases with acute watery diarrhoea (AWD) do not respond to antibiotics because they are mainly caused by viruses. The following factors are associated with increased spread and death from diarrhoeal diseases: Environmentovercrowding, inadequate water quantity and quality, insufficient sanitation facilities and scarcity of soap make it easier for diarrhoea pathogens to be transmitted. Faecal contamination of surface water is a common cause of diarrhoeal disease outbreaks. In a typical camp situation with multiple risk factors, a cholera outbreak can last between three and twelve weeks; in non-camp settings, deaths among Congolese refugee children in Tanzania in 1999 and Democratic Republic of Congo, the median duration was sixteen weeks (range: 3 to 59 weeks). Angola has experienced a prolonged cholera outbreak which lasted for years while the outbreak in South Sudan and Ethiopia could have lasted for up to two years. In more stable settings, increased frequency of diarrhoeal disease was associated with increased crude and under-five mortality rates in an investigation of 51 post-emergency camps in seven countries from 1998 to 2000; Populationgreater risk of death among the very young age (below two years of age). Risk can be increased by poor hygiene practices (personal, domestic, and environmental) and poor nutritional status. Low immunity prior to the infection can also increase the likelihood of transmission and prolong suffering among displaced persons. The natural history of diarrhoea is that most episodes will stop without treatment. As a result, the risk of death from diarrhoeal diseases is frequently underestimated. However, diarrhoea can lead to serious complications, such as:
Access to clean water is more of a challenge in Africa than in any other region of the world. The International Federation is scaling up its water and sanitation activities in many areas. Photo: Daniel Cima/ American Red Cross
Table 7-25: Serious complications of diarrhoea

Complication Description
Dehydration and death
The biggest threat from diarrhoea is not loose stool, but dehydration from excessive loss of body fluids and salts. Some patients lose up to 5-10% of their body weight. Dehydration may develop suddenly and death can occur soon thereafter if body fluids are not replaced immediately, particularly among young children. While the risk of diarrhoeal diseases is higher in a malnourished child, diarrhoea may lead to under-nutrition through loss of appetite, decreased absorption of nutrients, or withholding of normal feeding (due to cultural beliefs). Children suffering frequent episodes of diarrhoea may become stunted. Children with dehydration or diarrhoeal disease may develop fever. However, very high fever persisting after a patient has been rehydrated indicates the presence of another infection (e.g. otitis media, pneumonia, measles, malaria, meningitis, typhoid fever). Seizures may result from fever, dehydration, low blood glucose levels, or sodium overload. Children who have many episodes of diarrhoea are likely to develop persistent diarrhoea. It may be due to multiple infections of the same pathogens that cause acute diarrhoea. Many children in developing countries die from persistent diarrhoea particularly those who are malnourished.25
Malnutrition
Fever
Seizures Persistent diarrhoea
Cholera Cholera is an acute bacterial infection caused by Vibrio cholerae. It accounts for more than 150,000 deaths each year in developing countries and causes high morbidity and mortality in populations affected by natural disasters and conflict situations. Globally, the incidence of cholera has decreased, but in Africa, has increased considerably. Several outbreaks of cholera have occurred among displaced populations since 1990 in Malawi, Sudan, Nepal, Somalia, Burundi and Democratic Republic of the Congo.11 There are more than sixty serogroups of V. cholerae. For many years, most outbreaks world-wide were caused by V. cholerae serogroup O1, El Tor biotype. Since 1992, V. cholerae O139 has been identified as another causative agent for cholera outbreaks in South Asia. Note: The El Tor biotype causes a higher number of asymptomatic carriers and risk of transmission is higher because it can survive in fresh water for long periods of time. Cholera has a very short incubation period, ranging from less than one day to five days. Although infected persons excrete the bacteria in their faeces for seven to fourteen days, most do not become ill. However, a few cases develop painless, watery diarrhoea (due to a bacteria enterotoxin) that can quickly lead to severe dehydration. Vomitus, stools, soiled clothes and bed linen are highly infectious and need disinfection. Cholera attack rates in refugee settings may reach 5% (one in every 20 persons). Case-fatality rates for cholera may be as high as 50% if a community or health system is not prepared to deal with the outbreak. It should be 1% or lower. Laboratory confirmation is often delayed. This might be due to limited access to a competent laboratory. Often, however, there is a governmental unwillingness to declare a cholera outbreak since it can harm tourism and trade. Note: Any Air Way Bill (AWD) outbreak with adult deaths raises the suspicion of cholera and action should be taken accordingly.
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Bacillary dysentery (Shigellosis)
Dysentery is commonly defined as acute bloody diarrhoea. Although several organisms can cause dysentery, Shigella is the only cause of large-scale epidemics of dysentery throughout the world. Shigellosis, or bacillary dysentery, has caused high rates of illness and death in east and central Africa since 1992. In recent years, these outbreaks have become quite frequent during periods of civil unrest. Case-fatality rates for this illness can exceed 10%. Note: Bloody diarrhoea due to amoebiasis (infection with Entamoeba histolytica) is neither common nor severe and does not cause epidemics. S. dysenteriae (Sd) type 1 (Sd 1) is an unusually virulent organism. A very low dose of Sd 1 (less than 100 organisms) can cause severe clinical illness. The organism can also survive in the environment for a fairly long time. Individuals infected with Sd 1 excrete large numbers of bacteria in stool. The risk of Sd 1 outbreaks among displaced populations is high and up to one-third of the population might be infected. Attack rates in non-emergency situations are usually about 5%. The case-fatality rate can reach 10% in areas without proper treatment. The highest case fatality is observed among children, the elderly and the malnourished. Unfortunately, most strains of Sd 1 in Africa have developed resistance to commonly used antibiotics during the last few years. In some areas, only ciprofloxacine, a very costly antibiotic, is effective against Sd 1. The following table summarises the epidemiology of cholera and bacillary dysentery.
Table 7-26: Summary of epidemiology of cholera and bacillary dysentery
Cholera Bacillary dysentery
Causative agent Geographical distribution Transmission
Vibrio cholerae O1 or V. cholerae O139 Asia, Africa, Latin America Ingesting faecal-contaminated water (main route). Consuming contaminated food, seafood, fruits, and vegetables. Person-to-person contact (rare). Inadequate and unsafe water supply and food. Inadequate heating/reheating of food (even grain-based foods). Spreads at funeral ceremonies and feasts. Low acid levels in stomach. Incubation less than 1 day to 5 days. Asymptomatic: most infected persons do not become ill. Mild or moderate diarrhoea in 90% of cases. Profuse watery diarrhoea (rice water stools) and dehydration may develop in less than 10% cases. Vomiting (common.
Shigella dysenteriae type 1. Worldwide. Person-to-person contact. Direct contact with infected faecal material. Ingestion of contaminated food and water. Overcrowding. Poor sanitation and sub-standard hygiene. Unsafe water supplies.
Risk factors
Clinical features
Acute non-bloody diarrhoea Bloody diarrhoea may develop in 50% of cases with cramps, rectal pain, fever, mild-moderate dehydration. Complications: 10% of cases may develop sepsis, seizures, renal failure, and haemolytic uraemic syndrome, toxic megacolon.
Cholera
Bacillary dysentery
Case definitions
Suspected cholera In areas where cholera unknown to be present: A patient over the age of five years old develops severe dehydration or dies following acute watery diarrhoea. In an area where cholera is endemic: A patient over five years develops acute watery diarrhoea. Confirmed cholera Isolation of V. cholera O1 or O139 from stool or vomit of suspected case.
Suspected shigella When there is an unusual increase in the weekly number of cases or number of deaths from bloody diarrhoea. Confirmed shigella Confirmed by evidence of acute onset of bloody diarrhoea with visible blood in stool. In some situations, the presence of blood is verified by a health worker.
Case management of diarrhoeal diseases

The goal of case management for diarrhoeal diseases is preventing death from dehydration and circulatory collapse. Early diagnosis of patients with a diarrhoeal illness should be followed by prompt treatment to prevent death from dehydration. The main treatment for acute diarrhoea is rehydration. Stool losses should be replaced with appropriate fluids, feeding should be continued and unnecessary medicines avoided. The same principles can be applied to the treatment of persistent diarrhoea. Health care professionals, volunteers and community health workers (CHWs) must be trained to classify the level of dehydration among diarrhoea patients and manage as described in the table below.
Table 7-27: Classification and management of dehydration among diarrhoea patients
Clinical features Recommended rehydration therapy
Diarrhoea +/mild dehydration
< 4 fluid stools/day. Alert. Not thirsty and drinks normally. Little or no vomiting. General condition normal. No signs of dehydration. Skin pinch goes back quickly. 4-10 liquid stools/day. Thirsty and drinks eagerly. Dry conjunctiva, lips and inside of mouth. Urine flow reduced and concentrated. Skin loses elasticity and pinch reacts slowly. Pulse rapid. Respiration deep.
Increase fluid intake at home Teach caregivers, especially mothers of children with diarrhoea, to administer ORT 50 ml/kg body weight after each diarrhoea episode. Advise caregivers to return if watery stools increase, if child is eating or drinking poorly, has marked thirst, is vomiting, or develops other signs.* Oral rehydration therapy at an ORT unit or diarrhoea corner 100ml/kg body weight in 4 hours. Reassess patient every 4 hours to ensure sufficient ORS intake.
Moderate dehydration
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Clinical features
Recommended rehydration therapy
Severe dehydration
10 liquid stools/day. Frequently lethargic. Drinks poorly or unable to drink. Fluid loss > 8% of body weight. No urine flow in previous 8-12 hours. Eyes deeply sunken. Skin pinch reacts very slowly. Pulse may be rapid or barely detectable. Respiration deep and rapid.
Rapid intravenous rehydration at health facility Ringers lactate (Hartmanns solution) 150ml/kg body weight in 4-6 hours. Oral rehydration therapy to be instituted as soon as a person can take ORS.
The following table defines other treatment approaches for different diarrhoeal diseases:
Table 7-28: Summary of treatment for diarrhoeal diseases
Other diarrhoeal diseases ORS

Effective for diarrhoea due to rotavirus, E. Coli (enterotoxigenic). Required for cases with severe dehydration. Not useful at all.
Cholera
Dysentery
Mainstay of treatment for 80-90% of cases.
Can be useful.
IVF
Antibiotics
Specific drugs
Metronidazole (flagyl) for amoebiasis and giardiasis.
Required for 1% cases who develop severe dehydration. Appropriate for moderate or severe dehydration. Selective drug prophylaxis for close contacts. Tetracycline, cotrimoxazole, erythromycin, doxycycline, chloramphenicol, furazolidone.
Not often required.
Mainstay of treatment 5-day course
Dietary therapy
Increase fluids and food intake.
Ampicillin and cotrimoxazole not effective in recent ourtbreaks of SD 1vi. Increasing resistance to nalidixic acid. Ciprofloxacin effective but costly. Increase fluids and food intake.
Measles
Measles remains a major childhood killer, despite the availability of a safe and effective vaccine. In 2006, an estimated 242.000 people died of measles; about 217.000 of these deaths were among children under five years old who are the most vulnerable to measles. In 2006, about 74% of all measles deaths occurred in the WHO region of South-East Asia and only 15% in Africa (http://www.redcross.org/static/file_cont7323_lang0_3016.pdf). Nearly 600 children under five die from measles each day. Despite the efforts of the global Expanded Programme of Immunisation (EPI), measles is still endemic in many developing countries, especially where conflict prevents routine
immunisation.6 Considerable progress has been made in reducing the measles mortality by 68% worldwide (91% in sub-Saharan Africa), through the founding of the Measles Initiative in 2001, a partnership of the American Red Cross, CDC, WHO, UNICEF and United Nations Foundation. Reference the Measles mortality reduction strategy (attached in fact sheet). http://www.measlesinitiative.org/index3.asp Measles is an acute infection of the virus, Morbillivirus of the family Paramyxoviridae. The disease is spread through close respiratory contact with contagious air droplets. Infected persons can transmit the disease to susceptible hosts even before the appearance of the measles rash. Life-long immunity is acquired after measles infection. The case fatality rate in developing countries is generally in the range of 1 to 5%, but may be as high as 25% in populations with high levels of malnutrition and poor access to health care. People who recover from measles are immune for the rest of their lives2, 32 http://www.who.int/mediacentre/factsheets/fs286/en/). Measles can be particularly deadly in countries experiencing or recovering from war, civil strife or a natural disaster. Infection rates soar because damage to infrastructure and health services interrupts routine immunization and overcrowding in camps for refugees and internally displaced people greatly increases the risk of infection Measles outbreaks commonly occur in refugee settings, especially during the acute emergency phase. In general, even with relatively high immunisation coverage (<90%) a number of cases and epidemics occur after a massive population movement and disasters. Major outbreaks have occurred after disasters, notably after the 1991 Mt. Pinatubo volcanic eruption, after the 2005 South East Asia earthquake and the tsunami in Aceh.38 The following factors may promote the transmission and poor outcome from measles: Environment: Overcrowding increases the risk of secondary infection, which increases the severity of disease in all age groups.21 Health workers might fail to recognise measles cases and not give proper care to people with severe infection.4, 33 Disruption of power supplies and immunisation services interrupt the delivery of measles vaccine to children. General lack of awareness about measles within the community results in failing to seek appropriate health care for the sick and the spread of disease to others; Host: All unvaccinated persons are at risk of developing measles, but the risk of death is highest among children between the age of six months and five years. Immunisation non-responders, poor vaccination practices, malnutrition, chronic vitamin A deficiency, and pre-existing diseases increase the risk of death from measles by decreasing the bodys immunity. Measles can affect many body systems and most deaths occur due to secondary infections of the respiratory system and/or Gastro-Intestinal Tract (GIT). This is summarised in the table below. Remember that the incubation period of measles before onset of fever lasts between ten and twelve days. Measles is mostly infectious after four days before the rash until one or two days after the onset of the rash.
Bangladesh - One of 150 students at Sahen Cadet Play School in Tangail, receives a measles vaccination during the largest ever vaccination campaign in history. Photo: American Red Cross
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Table 7-12: Clinical presentation of measles
Clinical measles
Complications of measles
Prodromal fever Conjunctivitis Cough Koplik spots Measles rash
Respiratory croup, bronchiolitis, pneumonia, bacterial superinfections GIT diarrhoea, severe dehydration, malnutrition CNS convulsions, encephalitis Blood anaemia Skin mouth ulcers Eyes infections, blindness (Vitamin A deficiency) Ears, nose, Throat (ENT) middle ear infections, deafness
Note: Very sick children are more likely to develop and die from the viral complications and secondary bacterial infections. Severely malnourished children may have a milder rash but more severe disease.
Case management of measles

Managing cases of measles should be based on the severity of clinical presentation. Case management is summarised in the table below:
Table 7-13: Case management of measles
Measles severity Case management
Uncomplicated cases
Treatment is supportive (fever nutritional feeding if necessary).
control,
fluids,
Give vitamin A dose immediately upon diagnosis and another dose on the next day. Cases with non-severe eye, mouth or ear complications Give vitamin A dose immediately upon diagnosis and another dose on the next day. If pus is draining from eyes, clean eyes and treat with 1% tetracycline eye ointment. If mouth ulcers present, treat with gentian violet. If pus is draining from ears, clean ears and treat with amoxicillin (1st line) or co-trimoxazole (2nd line) for five days, as per national ARI policy. Treat malnutrition and diarrhoea, if present, with fluids and diet. Cases with severe, complicated measles (inability to drink/feed, vomiting, convulsions, lethargy, corneal clouding, extensive mouth ulcers, pneumonia). Refer to hospital. Treat pneumonia with appropriate antibiotic. Treat eye pus drainage or corneal clouding with 1% tetracycline eye ointment. Give vitamin A dose immediately upon diagnosis and another dose on the next day. If eye signs of vitamin A deficiency are present (i.e. night blindness, Bitot spots, corneal clouding/ulceration), give the child a third dose of vitamin A two to four weeks later.
Source: WHO
Control of measles
Table 7-14: Steps in measles control

Type of control Case management
Immunization in emergency and postemergency phases
Immunize population at risk as soon as possible. Ideally, all children, aged 6 months to 15 years, regardless of vaccination status or disease history, should be vaccinated. However, in resource-poor settings where vaccinating all children aged 6 months to fifteen years is not possible priority should be given to children aged six to fifty-nine months. Expand immunisation to sub-populations with high susceptibility; Children receiving vaccine before nine months of age must receive a second measles vaccination, which should be given as soon as possible after nine months of age (with an a one-month interval between doses); Vitamin A supplementation should be given to all children aged six months to five years. Inform health authorities if one or more suspected cases arise; Confirm outbreak and follow WHO guidelines; Give priority to case management and immunisation of groups at highest risk (e.g. children aged six months to fifteen years) in non-affected areas; Promote social awareness and immunization of previously unvaccinated children particularly those aged six months to five years; Conduct a measles immunization campaign; Isolation is not indicated. Source: WHO
Outbreak response
Note: it is not harmful to immunise a child who had previously received immunisation. A common cold is not a contraindication against measles immunisation.
Malaria
Malaria is endemic in more than 100 countries in the tropical and subtropical areas. In the last decade, the number of malaria cases has risen at an alarming rate particularly in Africa. This is probably due to the increasing resistance to anti-malarial drugs, ineffective spraying programmes, to the disease invading new geographical areas and being now transmissible at a higher altitude than it was ten years ago, and climate change in the form of warmer temperatures and variations in rainfall patterns (WHO). WHO estimates that there are more than 500 (WHO) million malaria cases annually resulting in more then (WHO) 1 million deaths, of which 90% are in sub-Saharan Africa, about 71% of them among children
Photo International Federation
Measles control in emergency and post-emergency settings involves two main measures: routine immunization for measles prevention, immunization campaigns in particularly vulnerable populations (camps etc.) and early response to measles outbreaks. Steps in these control measures are outlined in the table below.
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less than five years of age. In 2008 it is estimated 30% of malaria deaths in Africa are the result of outbreaks of malaria during emergencies (WHO source). More than 80% of complex emergencies are in malaria-endemic areas. Thus numerous epidemics of malaria have been reported among displaced populations with incidence rates ranging from seventy to 600 per 1000 population.44, 21, and 29. In complex emergencies located in high transmission areas, up to 50% deaths are due to malaria. Death rates as high as thirteen per day per 10,000 people were reported in north-eastern Kenya among Somali refugee communities in early 1998 following the El- Nino rains.1 Malaria is caused by four species of malaria parasites: Plasmodium vivax, P. ovale, and P. malariae or P. falciparum. These parasites are often transmitted through an infected female anopheles mosquitos bite, but transmission through blood transfusions can also occur. An acute illness can develop after a seven-day incubation period. In sub-Saharan Africa, over 90% of infections are due to P. falciparum whereas in other parts of the world e.g. East Timor and Afghanistan, have different infection levels for each species and a few cases could have mixed falciparum and vivax infections. It can be difficult to distinguish infections due to the four malaria species based on clinical symptoms alone. Many infected people, particularly those who are partially immune or have been taking anti-malarial drugs, do not show the signs and symptoms typical of malaria. Vivax malaria can cause anaemia, enlarged spleen and low birth weight in newborns while falciparum malaria can be fatal even in cases without drug resistant malaria. Most deaths from malaria are caused by P. falciparum. A small percentage of the total deaths from malaria are also caused by P. vivax, predominantly amongst the very young and very old. Case fatality for falciparum malaria can reach 10% even in a reasonably equipped hospital. Factors for spreading malaria in emergencies include: Agent: Increased possibilities for parasite breeding can result from environmental changes, inadequate malaria control measures or increasing resistance to anti-malarial drugs following wide-spread self-treatment; Environment: Emergency situations provide more opportunities for transmission due to insufficient shelter and overcrowding. Vector breeding sites can increase after climate change, environmental deterioration or settlements being located too close to surface water sources. The risk of death is greater where access to malaria treatment is very poor or nonexistent; Host: Not everyone infected with malaria parasites develops clinical malaria by reason of the level of the hosts pre-existing partial immunity. Displaced populations if they have migrated from non-endemic to or through highly endemic areas can be more susceptible to infections due to malnutrition, multiple infections or low immunity. The following table identifies vulnerable groups at risk from severe malaria and provides the WHO case definitions for prompt identification of individuals requiring immediate treatment.
Bednets distribution Photo International Federation
Table 7-29: Case definitions and vulnerable groups for different malaria parasites
Presentation Uncomplicated malaria Complicated malaria
Parasite species Case definition for emergencies
P. falciparum, malaria, ovale, vivax Persons with fever or history of it within the last forty-eight hours (with or without nausea, vomiting, diarrhoea, headache, back pain, chills, myalgia) where other obvious causes of fever have been excluded. Very young and very old, people with concurrent health conditions. Displaced people of all ages and sexes with low or partial immunity if they move from a low to a high transmission area.
Only P. falciparum Persons with fever and symptoms as for uncomplicated malaria but with associated signs of:* disorientation, loss of consciousness, convulsions, severe anaemia, jaundice, hemoglobinuria, spontaneous bleeding, pulmonary oedema, shock. Infants and young children, malnourished individuals, pregnant women, immuno-compromised adults. Displaced people of all ages and sexes with low or no partial immunity if moving from a low to high transmission area.
At risk group
* These manifestations can occur singly or, more commonly, in combination in the same patient. Note: Other infections can cause clinical illnesses that appear to be malaria. However, in endemic areas where laboratory tests are unavailable, all patients with fevers should be suspected as having malaria.
Prevention
Insecticide Treated Nets (ITNs): evidentially can have a protective efficacy similar to most childhood vaccines i.e. use of ITNs can reduce the number of under-five deaths from all causes by about 20% as well as half of the clinical malaria episodes. Insecticide Treated Nets (ITNs) also have a community effect i.e. they protect those sleeping under them as well as those living nearby. The main challenge of large scale ITN distribution is the low re-treatment rates. Long Lasting Insecticide Treated Nets (LLINs) are bed nets impregnated with deltamethritin compound. LLINs are effective for those sleeping under them all night, but provide partial protection for those sleeping in the same room. Longlasting bed nets do not need re-treatment over their life span. Zero fly is an insecticide impregnated plastic sheeting or tarpaulin used as a temporary roof or floor cover. Most insects do not like Zero fly which provides some protection for its users. Indoor Residual Spraying (IRS) is a highly effective intervention. Application has been limited by various factors such as its high cost, low community acceptance, and risk of insecticide resistance. Intermittent Preventive Therapy (IPT) given throughout pregnancy together with sulfadoxine-pyrimethamine (SP) during the second and third trimester has proved very effective in reducing severe anaemia and clinical malaria in pregnant women as well as the proportion of babies with low birth weight in sub-Saharan Africa. As the emergency situation stabilises, IPT and LLINs distribution can be integrated with other Maternal and Child Health interventions to increase ante-natal care (ANC) coverage and better health outcomes for mother and child. For areas with low sulfadoxine-pyrimethamine resistance, IPT should be introduced as soon as ante-natal care services begin. In areas with confirmed high sulfadoxinepyrimethamine resistance, the following website should be consulted (www.who.int/malaria/pregnantwomenandinfants.html). More research is needed to identify other suitable anti-malarials for IPT.
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HIV and IPT: Because sulfadoxine-pyrimethamine is less effective among women who are HIV positive, it needs to be administered on a monthly basis. It is also is recommended that all pregnant women receive monthly IPT where ante-natal care seroprevalence for HIV exceeds 10%. HIV positive women on cotrimoxazole prophylaxis do not require IPT. (www.who.int/malaria/pregnantwomenandinfants.html). More research is needed to identify other suitable anti-malarials for IPT. HIV and IPT: Because sulfadoxine-pyrimethamine is less effective among women who are HIV positive, it needs to be administered on a monthly basis. It is also is recommended that all pregnant women receive monthly IPT where ante-natal care seroprevalence for HIV exceeds 10%. HIV positive women on cotrimoxazole prophylaxis do not require IPT.
Case management
Prompt diagnosis and treatment of clinical malaria is the best means for preventing its progression to severe malaria and death particularly during the acute emergency phase when prevention of malaria is difficult. In a high malaria risk area where diagnostic capacity is limited, all patients with fever or history of fever within the past three days should be classified as having malaria until proved differently as shown in the table below.
Table 7-30: Case management of children with fever in malaria areas
Case description Management principles
In a high malaria risk area all children less than five years who have a fever (or history of fever) should be classified as having malaria. In low malaria risk or season, children with fever (or history of fever) are classified as having malaria and given an anti-malarial only if they have no runny nose, no measles or other obvious cause of malaria.
The high rate of malaria and the risk of disease progression to severe malaria or death justify the presumptive anti-malarial treatment based on clinical diagnosis for children under five. Parasitological confirmation of malaria infection is recommended for children under five.
Where resources permit, microscopy can be re-established as soon as possible with good monitoring to ensure accuracy of blood film-making and reading. Malaria is confirmed by demonstrating malaria parasites in thick or thin blood smears. In acute emergency settings, Rapid Diagnostic Tests (RDTs) or dipsticks may be used as they are simple to perform and to interpret and do not require electricity or training in microscopy. RDTs are included in the Interagency Emergency Health Kits basic units. RDTs can be used by peripheral health workers, other health providers and community volunteers who can be taught the procedure in a matter of hours.20 For many African countries, however, the widespread use of RDTs for national malaria control is not affordable. All identified malaria cases require effective anti-malarial treatment. Chloroquine is no longer effective against P. falciparum in most sub-Saharan African malaria-endemic countries. A change of national treatment policies, however, has been constrained by the high cost, limited availability and use of alternative anti-malarial therapies. Nevertheless, WHO recommends combination drug therapy that contains an Artemisinin Compound (ACT) as the first line therapy for all P. falciparum endemic areas. ACT effectively reduces infection, transmission and retards the development of drug resistance. The most promising ACT is the co-formulated single pill combination of artemether and lumefantrine (CoArtem). Unfortunately, because CoArtem is ten times more costly than chloroquine (USD 1.00 for children, 2.00 for adults). Many countries have adopted ACT as the policy standard, but continue supporting less effective drug regimens. Some patients with P. falciparum infection may develop severe life threatening illnesses and require complex medical management. Pre-referral administration of artesunate
Note: If an emergency situation limits access to patients, agencies should prioritise a single dose treatment protocol and observe all patients for one hour after taking the drugs to make sure they do not vomit and retreat anyone who vomits in less than an hour). The following table summarises the basic approach to malaria case management. Other measures might be required for patients with complicated malaria.
Table 7-31: Malaria case management Indication
Specific
Treatment
Non-falciparum malaria (P. vivax, P. ovale, P. malaria)
Mixed infection (P. vivax/P. falciparum)
Option 1: Chloroquine is first line treatment. Can add Primaquine to destroy liver stages of P. vivax and ovale but not for pregnant women; Option 2: Mefloquine; Option 3: Quinine; Option 4: Artesunate. Artemisinin Compound (ACT) (except with sulphadoxinepyrimethamine). If malaria burden is not excessive, laboratory confirmation via microscopy is preferred to Rapid Diagnostic Tests for differentiating species.
Uncomplicated malaria Severe P. falciparum malaria
ACT with SP, amodiaquine or mefloquine For pregnant women in first trimester, quinine or amodiaquine. Option 1: Artesunate suppository then IM Artemether or IV Artesunate (except for pregnant women in first trimester) Option 2: IV/IM Quinine then oral Quinine + Doxycycline or Clindamycin (Doxycycline contraindicated in pregnancy) Option 3: IV/IM Quinine then oral ACT (CoArtem, Artesunate/SP. Antipyretics (paracetamol) IV glucose plus glucose infusion Haematinics, blood transfusion** Fluid/electrolyte replacement (ORS, IVF) Broad spectrum antibiotics for concurrent bacterimea
Complications of malaria
* Reserve for multi-drug resistant malaria. Given alone or combined with other antimalarial drugs. ** Blood transfusion is necessary for anaemic patients with high parasitemia. Due to high risk of HIV transmission, transfusions should only be done to save life. See the Reproductive Health Care in Emergencies chapter for details on safe blood transfusion
suppository within twelve hours has proven effective reducing the risk of death for patients with severe malaria. It is not possible to standardise malaria treatment protocols for all displaced populations. The appropriate treatment policy must be based on up-to-date information on drug resistance patterns in the area. This is vital for displaced populations who are especially vulnerable because of low immunity from malnutrition, the lack of any previous exposure to malaria or lack of access to re-treatment if treatment fails. Local health authorities and relief agencies must share the information. As drug resistance develops rapidly, it is also important to evaluate second line or future treatments proactively. Drug efficacy monitoring can be done using WHOs standard procedures.48 Other causes of treatment failure, such as non-adherence, vomiting and poor quality drugs should also be monitored.
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Note: Treatment of Plasmodium falciparum gametocytes with primaquine is no longer recommended, as evidence of its effectiveness is inadequate, and it can be dangerous in glucose 6 phosphate dehydrogenase (G6PD) deficient individuals. Note: WHO maintains a database of national treatment protocols of emergency affected countries where these protocols exist. It might be recommended that protocols be adapted if necessary in a complex emergency. The database will eventually also include information on drug sensitivity, simple protocols for sensitivity testing and mapping of malaria and malaria risk (epidemiological, climatic, land use, etc) in complex emergency countries.
Control of malaria
Various strategies can be used to control outbreaks of malaria after natural disasters or in refugee settings, depending on the available resources and the local health priorities. Good surveillance is vital as is timely and quality information about malaria incidence that is needed by the Ministry of Health (MoH) and World Health Organisation (WHO) to make informed decisions about outbreak preparedness and response. Below are additional measures to be considered: If the outbreak is severe, mass anti-malarial treatment of all patients with fever is justified (preferably with a single dose). Laboratory confirmation may be necessary where drug resistance is a problem or the anti-malarial is expensive; Where mortality is high or referral systems are not available, Community Health Workers and volunteers should be trained to identify actively malaria cases and provide home based care for uncomplicated cases; Passive case finding for malaria is acceptable in chronic refugee settings when mortality is under control.45 Other measures for minimising exposure to malaria vectors/parasites among the affected population might be needed at different levels. Because indoor spraying with residual insecticide (house spraying) is fast and effective, it has been the most preferred, although it is expensive. With safe insecticides, it is very appropriate during the first two to three months when combined with the introduction of insecticide treated materials as soon as possible (Long Lasting Insecticide Treated Nets (LLINs). The following table summarises commonly used measures for malaria epidemic control:
Table 7-32: Malaria control measures at various levels, by expected effect
Expected effect For individual and family protection For community protection
Reduction of human/ mosquito contact. Destruction of adult mosquitoes. Destruction of mosquito larvae. Source reduction.
ITNs*, LLINs, repellents, mosquito coils, protective clothing, screening of houses. Use of domestic space spraying (aerosols). Peridomestic sanitation, intermittent drying of water containers. Improve sanitation, wastewater drainage. Motivation for personal and family protection.
Site selection. Residual indoor insecticides, space spraying, ultra-lowvolume sprays. Larviciding of water surfaces, intermittent irrigation, biological control. Environmental sanitation, provision of piped water, water management. Health education, community participation.
Social participation.
* Long Lasting Insecticide Treated Nets (Source: Malaria control among refugees and displaced populations, WHO 1996). For more information about source reduction, protection of susceptible groups, and interruption of transmission, read the Vector Control chapter.
Meningococcal meningitis
Outbreaks of meningococcal meningitis can occur in any part of the world. However, major outbreaks occur mainly within the semi-arid areas of sub-Saharan Africa, often known as the African meningitis belt, which extends from Ethiopia in the east to Senegal in the west. In these areas, sporadic infections occur in seasonal cycles while large-scale outbreaks have been reported every eight to twelve years during the past fifty years. Meningitis epidemics often reach their peak after twelve weeks and last about six months on average with or without intervention. 15 Due to climatic change, increased mobility of populations and the adaptation of the bacteria species, shorter intervals have been observed between outbreaks since the 1980s. These outbreaks have also occurred beyond the meningitis belt. Attack rates of meningitis during major outbreaks in Africa range between 100-800 per 100,000 individuals. Several meningitis outbreaks have been reported among displaced populations in Malawi, Ethiopia, Burundi and Zaire.24 These outbreaks have not been confined to the displaced population, but have been widespread through the whole area.21 It is predicted that there will be an increased number of outbreaks in future that are very much related to climate change, the occurrence of new strains (W 135) and slight changes amongst other strains. Meningitis is a very deadly bacterial infection of the central nervous system. Large outbreaks of meningitis are mainly caused by Neisseria meningitidis, better known as meningococci types A, B and C. 90% of outbreaks are caused by meningococci type A, but the W 135 strain is spreading.
Note: Meningitis due to other micro-organisms (viruses, fungi, TB, etc) does not cause epidemics.
The disease is transmitted by direct contact with respiratory droplets from the nose and throat of infected people. 2, 29 While mainly a disease of very small children, meningitis also affects older children and young adults (up to thirty years), especially those living in crowded conditions.29 The average incubation period is four days, ranging between two and ten days. The case fatality of meningitis depends on the time between the onset of the clinical disease and the start of proper medical care. Untreated meningitis has a case fatality rate of 50%, which can drop to 10% with treatment.29 The following risk factors may increase the transmission and risk of death from meningococcal meningitis: AgentThe meningococci can develop resistance to commonly used antibiotics; EnvironmentOpportunities for infection are increased by overcrowding, the dry season, in endemic zones, high rates of acute respiratory infections, insufficient hygiene, poor housing, limited access to health services and delayed detection of outbreaks; HostThe population might be more susceptible to infection due to pre-existing infections or malnutrition. Children less than one year are most susceptible to infections. Meningococcal disease can be either present as meningococcal meningitis (more common especially in epidemics) or meningococcal septicaemia (uncommon in epidemics, but highly fatal). Both forms of the disease can be present in an individual at the same time. A classic case of meningococcal meningitis is easily diagnosed. The following table summarises its clinical presentation:
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Table 7-15: Clinical presentation of meningococcal meningitis
Typical presentation
Atypical presentation (Infants under 1 year)
Acute onset of intense headache, high fever, nausea, vomiting, stiff neck, photophobia, impaired consciousness, convulsions, coma.
Irritability, refusal to feed, vomiting, fits, lethargy, bulging fontanel. Note: Onset is not always rapid. A stiff neck may be absent.
Note: Meningococcal septicaemia is difficult to diagnose outside an epidemic since the stiff neck symptoms are usually absent and the rash or purpura may not be obvious.
Case management
Sub-Saharan countries health care systems are generally weak. During major epidemics, it is impossible to admit all suspected cases and ambulatory treatment (oily chloramphenicol) combined with mass vaccination campaigns is commonly used to reduce the impact of outbreaks. Because meningococcal meningitis can be treated effectively, efforts should be focused on ensuring vaccines, drugs and trained staff are available. This saves lives and reduces disability and deaths during outbreaks. Engaging community leaders and volunteers to raise disease awareness and do community mobilisation during vaccination campaigns has proven highly effective. Patients with meningococcal meningitis should be managed according to the following principles: 41 Meningococcal meningitis is potentially fatal and each case should be seen as a medical emergency. Admission to a hospital or a health centre is necessary for diagnosis and treatment of cases. Antimicrobial therapy is essential and should be combined with supportive treatment. As patients contagiousness is moderate and disappears quickly after antimicrobial treatment, special facilities for isolation of the patient are not necessary. Community health worker and volunteer training is needed to ensure early detection and prompt treatment of cases. Anyone suspected of having meningitis should be referred to a health facility or hospital. Simple techniques for diagnosing meningitis should be used where specialised techniques are not available (such as lumbar punctures and culture of fluids). If several suspected cases of meningitis develop a rash, assume that they have meningococcal meningitis and do the following: Even if laboratory facilities are available, treatment should be started before results are known41. If lumbar punctures are possible, do them and send the fluid to a laboratory to confirm the diagnosis and to determine the type/strain of the causative agent for the meningitis outbreak. Care for each case in a separate area until twenty-four hours of treatment has been given. Keep accurate records of the number of cases and their ages. The following table summarises the management of meningitis in epidemic situations:
Table 7-16: Meningitis case management

Age group Probable pathogens Antimictrobial therapy (First Choice) Antimictrobial therapy (Alternative)
In epidemic situations All age groups In non epidemic situations Adults and Children > five years Children 1 month five years Neonates
N. meningitidis
Penicillin G or Oily Chloramphenicol
N. meningitidis S.pneumoniae
Penicillin G or Oily Chloramphenicol
H. influenzae S. pneumoniae N. meninigitidis Gram negative bacteria Group B streptococci Listeria
Ampicilin or Amoxycillin Chloramphenicol Ampicllin and Gentamycin
Ampicillin Ceftriaxone or Cefotaxime Cotrimaxozole Ampicillin Ceftriaxone or Cefotaxime Cotrimaxozole Ceftriaxone or Cefotaxime Ceftriaxone or Cefotaxime Chloramphenicol
Source: WHO
Control of meningitis
The simplest way of controlling the spread of meningitis during an outbreak is to prevent overcrowding. Other control measures include: Early Treatment: Actively finding cases and promptly treating them with a single injection of long-acting oily chloramphenicol (tifomycin), long-acting penicillin or ceftriaxone2, 21, 31. The dose of antibiotic can be repeated after twenty-four to fortyeight hours for patients who do not improve immediately. Mass Immunisation: An effective meningitis vaccine is available, which can control meningitis outbreaks due to serotypes A, C and W 135. A mass immunisation campaign should only be carried out at the onset of an outbreak. It is not useful if the epidemic is on the decline. Routine immunisation of young children against meningitis is not recommended within the Expanded Programme of Immunisation programme for the following reasons: Currently available vaccines (against meningococcal types A, C, Y, and W135) do not provide enough protection to children less than 1 eighteen to twentyfour months or who might have to be administered in several doses. It protects vaccinated people aged more than two years for one to three years. Possibility of carrying out such vaccination is questionable since the vaccines have limited effectiveness in young children41. Limited availability and relatively high cost of the meningitis vaccine. (See the Immunisation in Emergencies section for more details on immunisation for meningitis). Mass Chemoprophylaxis: WHO no longer recommends mass chemoprophylaxis during meningitis outbreaks. Carrying out selective chemoprophylaxis with rifampicin for household contacts may be effective but expensive. Because mass or selective chemoprophylaxis demands extensive resources, it is recommended that meningitis control be limited to active case finding and early treatment.2, 29, and 21.
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Tuberculosis
Tuberculosis (TB) is a contagious disease, someone in the world is newly infected with TB bacilli every second. The World Health Organization estimates that the largest number of new TB cases in 2005 occurred in the South-East Asia Region, which accounted for 34% of incident cases globally. However, the estimated incidence rate in sub-Saharan Africa is nearly twice that of the South-East Asia Region, at nearly 350 cases per 100 000 population. It is estimated that 1.6 million deaths resulted from TB in 2005. Both the highest number of deaths and the highest mortality per capita are in the Africa Region. The TB epidemic in Africa grew rapidly during the 1990s, but this growth has been slowing each year, and incidence rates now appear to have stabilized or begun to fall. TB is a major cause of chronic illness in many parts of the world accounting for 25% of all avoidable deaths in developing countries. About one-third of the worlds population is infected and each year there are 9 million new cases with 95% of TB cases being in developing countries. Of these cases, 75% are within the adult age group. 49
Over 85% of refugees originate from, and remain in countries with a high prevalence of TB, for example: In 1989, 25% of all adult deaths in one refugee camp in Somalia was due to TB; In 1990, 38% and 50% of all adult deaths in two camps in Eastern Sudan were due to TB; 49 In the 1990s in Kenya, the incidence of new patients with infectious TB in refugee camps was four times the incidence of the local population. This placed an extra burden on the Kenyan TB programme.
TB is caused by Mycobacterium. Leprosy is caused by a related Myco-bacterium. Infected individuals release contagious droplets when they cough, talk or sneeze. The droplets can be inhaled by susceptible adults and children. As long as viable tubercle bacilli are being discharged in the sputum, the disease is communicable. People with laryngeal TB are highly contagious. The most dangerous period for developing clinical disease is the first six to twelve months after exposure.2 The following factors increase the spread of disease or development of disease complications: Agent: Transmission of TB depends on both the number and virulence of bacilli released. There is also an increase in multi-drug resistant infections mainly as a result of incorrect or incomplete treatment.21 The recent and most worrisome development is the occurrence of extreme drug resistance strains, which do not respond to all commonly used first line and some second line drugs. The appropriate treatment for such patients is extremely expensive and takes a long time. The reported increase of Extreme Drug Resistance XDR TB patients in Southern Africa might increase the risk of further disease transmission and also enhance the spread of HIV/AIDS. Environment: Poor living conditions with overcrowding and inadequate ventilation can increase the spread of infectious agents from infected persons to susceptible hosts. A high rate of urbanisation takes place in countries with a high TB prevalence. Lack of access to clinical and to diagnostic services results in delayed diagnosis and a delayed start in the anti-TB treatment. Host: The risk of infection is highest in children aged less than three and lowest in late childhood with incidence increasing again among adolescents, young adults and the very old. Young children may die from military TB or TB meningitis. The risk of death from TB is higher among people with other illnesses as well as among the underweight and under-nourished.21 In some sub-Saharan African countries, 30% to 70% of TB-infected people have concurrent HIV infection which has become the leading cause of death amongst TB patients. Although HIV-infected patients experience similar signs and symptoms of TB as non-HIV infected
Note: A large proportion of clinical disease among African adults arises from reactivation of latent infections.
Prevention
The most effective method of preventing TB transmission is its diagnosis and the cure of its infectious. Community education is also essential to promote the self referral of TB suspects, to increase understanding about the need for adhering to treatment and to decrease TB stigma. Cured patients are often helpful teachers and supporters of new patients. Other preventive measures in major population displacement settings include the following: Bacille Calmette Guerin (BCG) vaccination prevents severe forms of TB among children and is recommended for all newborns through the Expanded Programme of Immunisation programme. BCG is not recommended for adults. Reducing overcrowding and ensuring good ventilation in health facilities. Separating hospitalized patients with TB from others for the first two weeks of treatment. Separating infectious TB patients from HIV positive individuals. Education on HIV prevention and providing condoms to TB patients through TB clinics. Note: Isoniazid prophylaxis is not recommended for infants except for those being breast-fed by smear positive mothers. If the infant is well, isoniazid should be given for the first six months before the BCG vaccine is administered. If the Internally Displaced Persons/refugee settlement is suddenly closed, Isoniazid can be stopped and the child vaccinated with BCG before departure (preferably one week later).
Case management
Although TB may be a major problem among disaster affected and displaced persons, it does not demand immediate attention during the acute phase of the emergency. However, once diseases such as measles, malaria and diarrhoea have been controlled, TB treatment programmes should be started in order to cure infected persons and prevent the disease from spreading. It is vital to agree on standard case definitions as well as standard treatment protocols, especially if the anti-TB regimen used by the displaced or disaster affected population is different from the anti-TB treatment for the host population.
The diagnostic is essential Photo: International Federation
individuals, a person infected with HIV is twenty-five times more likely to progress from infection to active disease and can result in the more severe forms of TB (e.g. meningitis) especially in children.
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The following table summarises the clinical presentation of tuberculosis:
Table 7-18: Clinical presentation of tuberculosis

Pulmonary tuberculosis Can occur with or without cavities. If untreated, 50% of cases will die within five years, 25% will be self-cured, and 25% will remain ill with chronic infectious TB. Key signs and symptoms in TB suspects > 15 years: productive cough > 3 weeks, or haemoptysis; and significant weight loss. Other common but less suggestive symptoms: chest pain breathlessness fever / night sweats tiredness; and loss of appetite. 80% are smear positive Symptomatic contacts need to be tested. Extra-pulmonary tuberculosis May occur in 15% to 20% of cases.
- Peripheral lymphadenitis, with swelling of cervical or auxiliary lymph nodes, chronic evolution with sinus and production of caseous discharge; and - Ascites due to TB peritonitis, without liver disease, or other symptoms of cirrhosis, with lymphocytes and protein in the fluid extracted by puncture. Less common presentation: - For assessment and definitive diagnosis (severe, lifethreatening forms, with dyspnoea, coma or other neurological symptoms (miliary TB, TB meningitis)); or - X-ray for cases with suspected TB pericarditis, TB arthritis, osteomyelitis (including Pott's disease (vertebral TB)).
Note: Children may produce no sputum and have non-specific symptoms. Managing TB cases begins by confirming the diagnosis. People with TB infection are primarily identified via sputum-microscopy which can be fairly complex. Sputum samples need to be examined under light microscopy by a well trained and experienced laboratory technician. Once TB is diagnosed and before initiating treatment, all patients must be questioned carefully on whether or not they have ever taken anti-TB drugs previously. Patients are then classified into four different categories using the following criteria: Site of disease (pulmonary or extra-pulmonary); Severity of disease; Bacteriological status (sputum smear positive or negative); and History of anti-TB treatment (new or previously treated): New case - a patient who has never had or who has taken anti-TB drugs for less than four weeks; Peviously treated case - a patient who has ever received anti-TB treatment for more than one month.
Patients come to take their pills, with their prescription from the state institution Photo: International Federation
Treatment categories are essential for prioritising TB treatment according to public health risk. Category I, the highest priority includes newly-diagnosed patients with pulmonary TB or severe extra-pulmonary TB and children with a score greater than seven. Category III is the lowest priority. The DOTS (Directly Observed Therapy Short Course) strategy developed by WHO has proved effective for limiting the spread of TB among disaster affected or displaced populations. In DOTS, all patients with confirmed TB take anti-TB drugs for six to eight months under the observation of volunteers, health workers or community leaders. Various short standard drug combinations are issued in two phases: Initial Phase treatment with three to five anti-TB drugs given daily or three times weekly under direct observation for two to three months. These drugs rapidly reduce the number of bacilli and prevent further disease spread. Note: All doses containing rifampicin are issued under observation;
The following table summarizes the treatment regimens for different TB categories.
Table 7-19: Recommended treatment regimen for different categories of TB36
Category Diagnosis of patient Treatment priority Initial phase Continuation phase
New smear-positive pulmonary TB New smear-negative pulmonary TB New cases of severe forms of extra-pulmonary TB Children with score of 7 or more Treated but sputum smearpositive: Relapse after treatment Treatment failure Treatment after interruption New smear negative pulmonary TB (not in category I) New cases of less severe forms of extra-pulmonary TB
High priority because they pose a high public health risk
2EHRZ (2SHRZ) or 2 E3 H3 R3 Z3 (2 S3 H3 R3 Z3 )
4 H3 R3 (6 HE)
II
Medium priority
2 SHRZE / 1 HRZE
5 H3 R3 E3
III
Low priority and should not get treatment at initiation of TB programme or if resources are scarce
2 H3 R3 Z3
4 H3 R3 (6 HE)
E = Ethambutol; H = Isoniazid; R = Rifampicin; Z = Pyrazinamide; S = Streptomycin The number before the drug abbreviations is the duration of that phase in months. The subscript after a drug abbreviation (e.g. 3) represents the number of doses of that drug per week. Note: Some authorities recommend a seven-month continuation phase with daily isoniazid and rifampicin (7HR) for Category I patients with serious forms of disease, e.g. TB meningitis, military TB, spinal TB with neurological signs. All TB drugs are safe in pregnancy and lactation except streptomycin which can be substituted with ethambutol. Although most TB patients can complete treatment on an outpatient basis, those who are very ill when starting their treatment might require hospital admission. Ongoing education is essential for sputum positive TB patients and for their family members about preventive measures such as covering the mouth when coughing. Nutritional supplements and rehabilitation can benefit those who might be at risk of malnutrition. The active follow-up of all defaulters (non-adherers and patients who interrupt their treatment even if it is only one attendance) is critical for assuring good treatment adherence that will cure TB patients. Measures to promote adherence can include: Direct observation of treatment; Home visits to trace defaulters;
Continuation Phase treatment with two to three drugs given three times a week under direct observation for four to six months. In some cases (e.g. during refugee repatriation), two drugs for six months given daily unsupervised, but in fixed-dose combination form. The sterilising effect of these drugs eliminates any remaining bacilli and prevents subsequent relapse.
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Good relationship between staff and patient; Continuing education programme for staff, patients and families, and the community; and Clinic setting acceptable to patients and staff. Note: much of this work can be done by community volunteers, CHWs or other members of the community.
Tuberculosis treatment for children

About 10% of all TB patients are children whose infection was acquired from an adult family member with sputum positive TB. Diagnosing TB in children is more difficult because they often have non-specific symptoms without a productive cough and their sputum is rarely positive. Since children represent about 10% of all TB cases, other techniques for diagnosing TB in children are needed. The tables below present score charts for diagnosing childhood TB after one month of nutritional rehabilitation.
Table 7-20: Score chart for diagnosis of tuberculosis in children
Feature 0 1 3 Score
Duration of illness Nutrition (% WFA) Family TB (Past or present)
< 2 weeks > 80 None
2 4 weeks 60 80 Reported by family
> 4 weeks < 60 Proved sputum positive
Table 7-21: Score chart for diagnosis of tuberculosis in children46

Other features Score
Positive tuberculin test Large painless lymph nodes, firm, soft, sinus in neck, axilla, groin Unexplained fever, night sweats, no response to malaria treatment Malnutrition, not improving after four weeks Angle deformity of spine Joint swelling, bone swelling or sinuses Unexplained abdominal mass or ascites Central nervous system signs (change in temperament, fits or coma) Total score
3 3 2 3 4 3 3 3
Note: When score is 7 or more, treat for TB. Anti-TB drug regimens for children are the same as for adults except that streptomycin should be avoided. Drug dosages will vary according to the childrens weight and further adjustments during the course of the treatment are needed as children can rapidly regain lost weight.
Management of TB/HIV
All patients with concurrent TB and HIV infection need monitoring for opportunistic infections and referred for a thorough clinical assessment and appropriate treatment. Patients often respond well to TB treatment, but can suffer side effects from the TB drugs. Because severe, even life-threatening reactions occur more frequently following treatment with Thiacetazone, this anti-TB drug is not recommended for use in emergency situations.
Control of tuberculosis
The aim of TB control in refugee situations is to reduce the morbidity, mortality and transmission of TB. According to WHO, TB control strategy requires: Political commitment to TB control by authorities at different levels; Passive case-finding and diagnosis by smear microscopy; Treatment by directly observed therapy, using short-course chemotherapy; and One person in charge of managing the TB programme; A regular drug supply system; Health workers trained in the management and application of TB control;46 Monitoring TB patients by a standard TB recording and reporting system.50 Although the short-course anti-TB treatment with multiple drugs can limit the spread of TB in crowded settlements, establishing a TB control programme in some situations can cause more harm than good for the following reasons: TB requires six to eight months treatment that might not be completed by migrating populations; Treatment failure may lead to the development of multi-drug resistant bacilli50. TB control programmes might be appropriate under certain conditions as shown in the table below:
Table 7-22: Implementation of a TB control programme
TB programme not recommended TB programme recommended
During the emergency phase following the population displacement. During warfare of significant insecurity. Very unstable population (e.g. nomadic or population moving up and down a border. Major health problems not fully addressed.
Emergency phase is over (death rates <1 per 10,000 population per day. Security in the camp envisaged for at least six months. Stability of the camp for at least 6 months. Basic needs of water, adequate food, shelter and sanitation are available. Laboratory services for sputum smear microscopy will be available. Essential clinical services and basic drugs are available. Data indicate that TB is an important health problem. Sufficient funding and drug supplies available for at least twelve months.
Limited financial resources.
Agreement on whether or not to start a TB programme and the TB control policies to be implemented should be reached as early as possible among all partners (national TB control authorities and NGOs). Drug procurement, establishment of a laboratory and training, can take over three months to complete. The following table summarizes key steps in setting up a TB control programme:
Note: In general, routine HIV testing for displaced people with TB is not recommended due to possible stigmatization.
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Table 7-23: Key steps in establishing a TB control programme
1. Identify lead agency i.e. NGO, NTP 2. Prepare budget 3. Appoint TB Coordinator (possibly 1 per 50,000 population) with a contract for at least twelve months 4. Assess staff needs, develop job descriptions, and recruit staff 5. Train staff - TB coordinators, nurses, laboratory technicians, community health workers 6. Identify secure storage facilities 7. Produce local TB control protocol
8. Agreement with NTP authorities of host country on: Integrating refugee TB control programme with NTP; Drug regimens to be used; Coverage of local population in TB control programme; Referral of seriously-ill patients to local hospitals; Laboratories suitable for quality control of smear examination; Procurement of drug stocks and reagents; Procedures for follow up of cases in repatriation phase; Programme evaluation.
9. Establish reporting system
HIV/AIDS
HIV (Human Immunodeficiency Virus) infection has become the fourth biggest killer. Every day, over 6800 persons become infected with HIV and over 5700 persons die from AIDS, mostly because of inadequate access to HIV prevention and treatment services. In 2007, advances in the methodology of estimations of HIV epidemics applied to an expanded range of country data have resulted in substantial changes in estimates of numbers of persons living with HIV worldwide. The estimated number of persons living with HIV worldwide in 2007 was 33.2 million [30.636.1 million], a reduction of 16% compared with the estimate published in 2006 (39.5 million [34.747.1 million]) / (UNAIDS/WHO, 2006). The single biggest reason for this reduction was the intensive exercise to assess Indias HIV epidemic, which resulted in a major revision of that countrys estimates. Important revisions of estimates elsewhere, particularly in subSaharan Africa, also contributed. Of the total difference in the estimates published in 2006 and 2007, 70% are due to changes in six countries: Angola, India, Kenya, Mozambique, Nigeria, and Zimbabwe. In both Kenya and Zimbabwe, there is increasing evidence that a proportion of the declines is due to a reduction of the number of new infections which is in part due to a reduction in risky behaviours.18 http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf Although the prevalence among many displaced populations is not known, HIV/AIDS has become a serious problem in emergencies. Many countries affected by conflict also have a high HIV prevalence with mortality rates from HIV/AIDS exceeding conflictrelated mortality. Since the beginning of the epidemic, the cumulative total of AIDS orphans (defined as those who have lost their mother before reaching the age of fifteen) has raised to 11.2 million.18 Two types of retrovirus have been identified as causative agents for HIV: type 1 (HIV-1) found worldwide, has many sub-types (A to K) and is the main cause of global pandemic; the less aggressive or transmissible type 2 (HIV-2) has an associated slower disease progression and is mainly found in West Africa, Mozambique and Angola.2 HIV infection can be transmitted by contact with contaminated blood or bodily fluids. Up to 90% infections among adults and adolescents are acquired via unprotected sexual contact while 5% to 10% of HIV transmission occurs through blood transfusion and
Note: Even though HIV transmission through breastfeeding is possible, WHO continues to recommend this form of feeding for developing countries where the benefits of breastfeeding outweigh the risk of HIV transmission.
Note: In emergencies, when seropositive mothers deliver or in areas where HIV

prevalence is high, HIV prophylaxis should be used by treating the mother at the onset of labour with Nevirapine and also the newborn. There are other similar schemes, but the Nevirapine approach is most convenient. The prophylaxis benefits the baby to great extent, even when breastfed afterwards. In some countries, this is already widely practised while in others it needs scaling up. Consult, therefore, the MoH to confirm if the ARV prophylaxis is acceptable. The natural history of HIV infection comprises of an acute/primary phase that may last up to six months followed by an early/clinically latent phase that typically lasts three to ten years. AIDS is a fatal clinical condition that develops in the late clinical stage of the HIV infection and is characterised by the ultimate immune collapse. Despite significant advances in HIV/AIDS research, AIDS remains a disease without a cure. Available antiretroviral drugs only arrest the diseases progression and improve the quality of life. The figure below illustrates the major stages of HIV and possible opportunities for interventions.
Figure 7-8: HIV/AIDS timeline
The HIV/AIDS timeline
Seroconversion HIV Asymptomatic period Death Impact
Prevention Positive living
Treatment support Impact mitigation
The following factors can promote the spread of HIV/AIDS: Agent: the HIV virus differs from other disease causing organisms because it is not experienced as a single event. People can acquire multiple HIV infections with different species over time, which are constantly undergoing mutation and developing resistance to existing antiretroviral treatment. Secondly, the virus continually interacts with ones immune system, gradually destroying the bodys CD4 lymphocytes to defeat the bodys capacity to fight both HIV and other opportunistic infections;
contaminated surgical instruments, syringes and needles. More than 90% of children are infected by their HIV positive mothers who infect their children during pregnancy, delivery or while breastfeeding.
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Environment: The root causes of complex emergency situations such as insecurity, poverty, political instability, conflict and powerlessness fuel the rapid spread of the HIV/AIDS infection. The risk of transmission among displaced populations is greater be because of increased sexual violence, social disruption of families and communities and the weakening of social norms which lead to unsafe sexual practices. Inadequate resources can hamper HIV/AIDS prevention and care resulting in low general awareness information on HIV/AIDS, the lack of universal precautions, unavailability of condoms and increased HIV transmission via contaminated blood transfusion and mother-to-child transmission; Host: Evidence shows that in emergency settings, the risk of HIV exposure can vary for different populations: War can accelerate HIV transmission among displaced communities with initially high HIV prevalence through rape and sexual exploitation although it can be difficult to prove that victims were not infected prior to being raped; The risk of HIV transmission is low wherever HIV prevalence rates are initially low and a displaced population remains isolated. This situation was observed in Sierra Leone and Angola despite the decades of war. Migration of displaced populations with low pre-conflict prevalence levels to urban areas can increase HIV exposure as was observed in Sierra Leone between 1991 and 2002. On the other hand the risk of HIV transmission for a host population can increase after the influx of a population with high pre-conflict prevalence levels of HIV. An example of this situation is when Zambian refugees were being repatriated to Angola with low HIV prevalence. People already infected with HIV suffer rapid physical deterioration during natural disasters or complex emergencies due to lack of food, clean water, hygiene, depleted household income and greater medical expenses. Presence of peacekeepers, military forces, and other armed groups may increase risk of HIV/AIDS transmission. Children are more vulnerable due to loss of parents, lack of education and sexual exploitation.
Figure 7-9: Example of poor media reporting
Various media reports made claims about the spread of HIV among Internally Displaced Persons (IDPs) in Burundi, Colombia, Liberia, Nepal, Somalia and Uganda despite the fact that HIV prevalence has never been measured in these populations. Although news coverage about the HIV situation in Sudan has attempted to provide a more balanced and informed account of the reality on the ground, no mention was made that the 1% HIV prevalence among IDPs was the same as the general nondisplaced Sudanese population in 2002. Such information could help to quell growing fears that IDPs are responsible for spreading HIV in the country; a claim which remains groundless.
Minimum HIV/AIDS intervention in emergencies

HIV and AIDS constitute not just a health issue but a problem that affects the sociocultural fabric, human rights and long-term economic well-being of IDPs as well as the local population with which they interact. For many years humanitarian agencies did not realise the need for preventing HIV in the acute emergency phase due to competing priorities, lack of both funds and technical know-how. Since 2000, there has been increasing recognition of the need to address HIV/AIDS within a wider humanitarian response for high as well as low HIV/AIDS prevalence settings. If not, the long-term impact of HIV/AIDS might gradually exceed the initial crisis event and reverse gains made through other humanitarian efforts.
Figure 7-10: Objectives of UNHCRs HIV and refugees strategic plan Protection ensures that refugees, asylum-seekers and other persons of concern who are affected by HIV and AIDS can live in dignity, free from discrimination, that their human rights are respected and that they can enjoy the highest attainable standard of physical and mental health without discrimination; 2. Coordination and mainstreaming ensure that HIV policies and interventions for refugees are coordinated, mainstreamed and integrated with those at the international, regional, sub-regional, country and organisational levels; 3. Durable solutions develop and incorporate HIV policies and interventions into UNHCRs programmes for durable solutions including voluntary repatriation, local integration and resettlement in order to mitigate the long-term effects of HIV. 4. Advocacy for HIV-related protection, policy and programme integration and sub-regional initiatives for refugees and other persons of concern in a consistent and sustained manner at all levels; 5. Quality HIV programming ensures appropriate and integrated HIV interventions for refugees, Internally Displaced Persons, returnees and other persons of concern in accordance with national programmes in host countries and countries of return; 6. Prevention reduces HIV transmission and HIV morbidity through the implementation of culturally and linguistically appropriate health and community based interventions; 7. Support, care and treatment reduces HIV morbidity and mortality and include access to antiretroviral therapy when available to surrounding host populations when appropriate; 8. Assessment, surveillance, monitoring and evaluation improves programme implementation and evaluation; 9. Training and capacity building improve HIV related skills and capacities of UNHCR, its partners as well as refugees and other persons of concern; 10. Resource mobilisation increases funds and moves beyond traditional donors to ensure that the objectives stated in this strategy are achieved. 1.
HIV and AIDS interventions must not be implemented in parallel, but integrated within and complementary to existing programmes. The following matrix proposes multi-sector interventions that can be applied to different emergency phases in any HIV prevalence setting.
Table 7-33: Guidelines for minimum HIV/AIDS interventions in emergency settings
Sector response Assessment and monitoring Emergency preparedness Minimum response during acute emergency phase Assess baseline data; Set up and manage shared database; Monitor activities. Comprehensive postemergency response Maintain database; Assess data on HIV/AIDS prevalence, knowledge, practice and impact; Monitor and evaluate all programmes; Draw lessons from evaluations.
Conduct capacity and situation analysis on HIV/AIDS; Map current HIV/AIDS services and high risk practices (including injection drug use); Assess current practices when applying of universal precautions; Assess HIV/AIDS education options for youths; Develop indicators and tools.
Below are the ten objectives of UNHCRs HIV and Refugees Strategic Plan for 20052007.
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Sector response Protection
Minimum response during acute emergency phase Prevent and respond to sexual violence and exploitation; Protect orphans and separated children; Ensure access to condoms for peacekeepers, military and humanitarian staff.
Comprehensive postemergency response Involve authorities to reduce HIV-related discrimination; Scale up prevention and response to sexual violence and exploitation; Strengthen protection for orphans, separated children and young people; Institutionalise training for uniformed forces on HIV/AIDS, sexual violence and exploitation and nondiscrimination; Set up HIV-related services for demobilised personnel. Establish health management committees; Organise awareness campaigns on hygiene and sanitation targeting people affected by HIV.
Review existing protection laws and policies; Promote human rights and best practices; Minimise risk of sexual violence, exploitation and discrimination; Train uniformed forces and humanitarian workers on HIV/AIDS and sexual violence; Train staff on HIV/AIDS, gender and non-discrimination.
Water and sanitation
Train staff on HIV/AIDS, sexual violence, gender and non-discrimination.
Consider HIV/AIDS in water and sanitation planning.
Shelter and site planning Education
Ensure safety of potential sites Train teachers on HIV/AIDS, sexual violence and exploitation.
Establish safely designed sites Ensure childrens access to education; Prevent discrimination by HIV status.
Plan orderly movement of displaced Educate girls and boys (formal and nonformal); Provide life skills-based HIV/AIDS education; Monitor and respond to sexual violence and exploitation in educational settings.
Prevention via BCC/IEC
Develop basic BCC/IEC strategy; Develop culturally appropriate IEC materials in local language; Involve key beneficiaries; Conduct awareness campaigns; Store key documents outside potential emergency areas.
Provide information on HIV/AIDS prevention and care.
Scale up BCC/IEC; Monitor and evaluate activities.
Health
Adapt/develop protocols; Train health workers on universal precautions, STI and OI treatment and PEP; Train peer educators; Plan and stock medical supplies and PEP prophylaxis; Plan quality assurance mechanisms; Develop instruction leaflets; Train staff on RH issues and kits; Plan for gender based sexual abuse prevention; Support existing prevention and care initiatives; Check PMTCT protocol on Nevirapine prophylaxis.
Ensure access to basic health care for most vulnerable groups; Provide basic RH services; Provide GBSV prevention, abuse and case actions; Ensure safe blood supply; Ensure universal precautions; Ensure access to safe delivery and Nevirapine prophylaxis.
Forecast longer-term needs, secure regular supplies; Ensure appropriate training for staff; Palliative and homebased care Treatment of OIs and TB; Provision of ARV treatment; Safe blood transfusion services; Comprehensive RH services; Ensure/monitor/reinforce universal precautions in health care; Use of Nevirapine or equivalent prophylaxis.
HIV at Workplace
Review personnel policies for PLWAs working in humanitarian operations; Develop policies to minimise discrimination; Stock materials for PEP.
Prevent discrimination by HIV status by staff management; Provide PEP prophylaxis to health workers.
Build capacity for people living with AIDS support groups; Establish workplace policies to eliminate discrimination against people living with AIDS; PEP for all humanitarian workers readily available; Access to condoms, where possible.
Although HIV interventions cannot be considered a priority in low prevalence settings, strong advocacy can prompt key actors to apply the minimum response appropriate to a particular situation. For high HIV/AIDS prevalence settings, adopting the above guidelines is more urgent in order to mitigate the HIV/AIDS epidemics. Determining which interventions are appropriate for natural disasters depends on the evolution of the disaster, the existing HIV prevalence and the government authorities, humanitarian agencies and donors capacity and readiness. Note: An essential minimum package for HIV prevention has been designed to address the above priorities for a population of 10,000 persons per month. For more details about Minimal Initial Service Package and HIV/AIDS, refer to the Reproductive Health in Emergencies chapter. For more details about caring for AIDS orphans, refer to the Food and Nutrition chapter.
Sector response
Minimum response during acute emergency phase
Comprehensive postemergency response
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Scale up of HIV/AIDS interventions in post-disaster phase

During the post-conflict or rehabilitation phase, it is possible to expand HIV/AIDS services for displaced persons in line with national AIDS programmes. The discussion below is based on the assumption that although volunteer testing and counselling, antiretroviral treatment is currently not feasible for most post-disaster settings. It is anticipated that this might change in the near future as high drug costs and other barriers are addressed. Assessment/surveillance: Insufficient data on HIV interventions, prevalence and behaviour among refugees and displaced populations shows that governments, UN agencies and NGOs have not prioritised this area. Comprehensive multi-sector HIV assessments in the post-disaster phase are needed to direct programming and provide a baseline for monitoring and evaluating their effectiveness. Serial HIV prevalence and behavioural surveillance studies can be conducted among refugees and Internally Displaced Persons that are a sufficient sample size to enable the comparison of results according to displaced and non-displaced populations, gender and age; Diagnosis: It is not possible to confirm HIV infection without an antibody test. However, voluntary HIV testing and counselling has been considered a low priority in refugee settings, except where strict confidentiality can be maintained and the needs of HIV/AIDS patients can be met. In non-refugee disaster settings, determining the HIV status of the affected population is very often even more complicated. Large-scale testing for HIV among refugees is not recommended. In some cultures, revealing ones HIV-positive status can lead to outright rejection and even physical harm to infected individuals from all levels: the partner, family, and community. If testing also shows high HIV rates in a refugee population, the entire population might be stigmatised in the eyes of the host population. Resettlement can be more complex as countries do not wish to absorb the burden of caring for refugees who are HIV positive or have AIDS. (For a summary of the UNAIDS/WHO position on mandatory HIV testing in refugee situations, please see the appendix at the end of this chapter). The WHOs Clinical Staging can be used to stage patients once HIV infection is confirmed with an antibody or a virological test. It is useful for determining prognosis, monitoring patients clinical progress and prioritizing the use of preventive interventions. Apart from this, it is particularly useful for providing guidance about when to start or review an Anti-RetroViral drug therapy as well as assess clinical response to therapy in the absence of appropriate laboratory tests. (For the revised WHOs revised Clinical Staging in Adults and Adolescents see appendix at the end of this chapter).
This CD4 machine at Molo Hospital allows HIVpositive patients' health to be monitored more accurately. Photo: Brendan Bannon/ International Federation
The following table presents WHOs recommendations for initiating Highly Active Antiretroviral Therapy (HAART, subsequently referred to as ART) in adults and adolescents with confirmed HIV infection:
If CD4 testing is not available
If CD4 testing is available
All patients with WHO stages III and IV disease; Patients with WHO stage II with TLC < 1200/mm3.
WHO stage I or II HIV disease if CD4 count < 200/mm3; WHO stage III disease if CD4 < 350; WHO stage IV disease, irrespective of the CD4 cell count; Asymptomatic patients with CD4 <350 should be observed and CD4 count monitored regularly. If such patients have been in long term care, ART should be initiated before CD4 count falls below 200 cells / mm3 e.g. when CD4 count is between 200 and 250 cells/mm3 .
Treatment in the early years of the pandemic, was mostly through interventions focused on the prevention of new infections by increasing public awareness and advocating for behaviour change. The majority of people already infected could only access palliative care because the cost of antiretroviral drug therapy was prohibitive. Fortunately, the last few years have seen the introduction of services that can reduce the suffering of People Living with HIV/AIDS (PLHIV). However, it cannot be over emphasised that the mainstay of managing the HIV/AIDS epidemic still relies primarily on prevention and advocacy for behaviour change: Chemoprophylaxis during deliveries is practiced in some countries but not everywhere. In emergencies, when seropositive mothers deliver or in areas where HIV prevalence is high, AntiRetroViral (ARV) prophylaxis should be used. Single dose Nevirapine must be administered to the mother at the onset of labour and Nevirapine syrup to the newborn immediately after delivery. Although there are other more efficacious ARV regimens for the prevention of mother-to-child transmission, the single dose Nevirapine approach is very convenient and practical for large scale implementation. The prophylaxis benefits the baby to a great extent even when breastfed afterward. Before adopting this intervention, however, it is important to consult the MoH and confirm which ARV prophylaxis is acceptable; Highly Active Antiretroviral Therapy (ART) has been shown to be effective in reducing morbidity and mortality in clinical and observational studies and in practice in the western world. These findings brought about an ethical challenge to increase access to treatment in developing countries. Unfortunately due to the high cost of AntiRetroViral (ARV) drugs and the required patient monitoring costs, most HIV infected individuals in the developing countries cannot access this life saving care; The goals of Highly Active Antiretroviral Therapy (ART) are to improve the quality of life of those infected with HIV, reduce HIV related morbidity and mortality by restoring and preserving their immune function and maximally suppressing viral replication. To achieve this, a minimum three antiretroviral drugs from at least two different classes must be administered in combination bearing in mind the efficacy of the regimen as well as the tolerability, affordability and availability of the drugs. The following box illustrates the standard first line regimens for several countries in sub-Saharan Africa.
Table 7-34: WHO recommendations for initiating ART in HIV-infected adults and adolescents
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Figure 7-11: First line HAART regimen for adults and adolescents
Stavudine (d4T) or Zidovudine (AZT) + Lamivudine (3TC) + Nevirapine (NVP) or Efavirenz (EFV)
Because HIV management is evolving, rapid changes in treatment and care are likely to occur. National treatment guidelines are likely to be amended or revised as a result of new evidence or changes in drug availability. Table 7-35: Other treatment for HIV positive patients
1. Identify the presence of any existing illnesses particularly the common and serious opportunistic infections. Screening for TB should be carried out in all patients. This should largely be based on the history and examination; routine chest x-rays are not required in all patients. 3. Review concomitant medications including traditional therapies, alcohol, cigarette use and non-prescribed drug use. 5. HIV positive patients need multivitamin supplementation particularly when nutritional requirements might not be adequately met. Multivitamins can act as potent antioxidants and reduce HIV replication, slowing disease progression. 2. HIV infection is a sexually transmitted infection, thus all HIV positive patients should be assessed for symptoms of STIs and syndromic management provided where indicated. 4. All HIV positive patients must be started on cotrimoxazole preventive therapy (unless contraindicated). 6. Clinical evaluation of the patient should include weight, nutritional and social assessment as well as assessment of other factors that may impact on adherence.
Diseases from the animal sector and other emerging diseases

Several diseases have surfaced recently, which have become major threats in emergency and non-emergency situations. During conflicts communicable diseases can transported by displaced populations into regions where the disease is not endemic. Wherever the infectious agent is new, the affected populations will lack the immunity to defend themselves. Other factors promoting the spread of emerging diseases in stable populations include changing climatic conditions as well as human behaviour, increasing interaction among humans and animals and the development of more virulent infectious agents. An estimated 75% of emerging diseases may be zoonotic in origin. (WHO defines zoonotic diseases as those infections and diseases that are naturally transmitted between animals and humans). Most zoonotic diseases are of viral origin and likely to be vectorborne. Diseases can spread from animals to humans due to the following: Expanding human settlements into wildlife habitat (e.g. rabies); Global trade of domestic and wild animals and exotic pets (e.g. salmonella, monkeypox);
The remainder of this section will focus on zoonotic and other emerging diseases that have gained increasing prominence using the following classification: Viral diseases viral haemorrhagic fevers (Dengue, Rift Valley fever, Ebola, yellow fever), avian influenza, SARS, hepatitis, polio; Bacterial diseases typhoid fever, tetanus, relapsing fever and leptospirosis. Parasitic and other diseases amoebiasis, giardiasis, hookworm, roundworms and scabies.
Viral Hemorrhagic Fevers (VHFs)

VHFs refer to a group of illnesses caused by four distinct families of RNA viruses arenaviruses, filoviruses, bunyaviruses and flaviviruses. In general, clinical symptoms of people infected with VHF viruses often include haemorrhage (bleeding). Although some types of haemorrhagic fever viruses cause relatively mild illnesses, many of them cause severe, life-threatening diseases4. Rodents and arthropods, rather than humans, are the main reservoirs for VHF viruses. The multimammate rat, cotton rat, deer mouse, house mouse and other field rodents are other reservoir hosts. Arthropod ticks and mosquitoes serve as vectors for some viruses. But, the hosts for Ebola and Marburg viruses remain unknown for the moment. Depending on the presence of their particular host species, viruses that cause VHF are distributed over much of the globe. Some VHF viruses are transmitted when humans have contact with urine, faecal matter, saliva, or other body excretions from infected rodents. Arthropod vectors often spread Viral Haemorrhagic Fever (VHF) viruses when a vector mosquito or tick bites a human or when a human crushes a tick. Some vectors can spread the virus to animals and livestock. Humans become infected when they care for or slaughter animals. Ebola, Marburg, Lassa and Crimean-Congo Haemorrhagic Fever viruses are transmitted from one person to another, once an initial person has become infected. With a few noteworthy exceptions, there is no cure or established drug treatment for VHFs. However, careful clinical management by experienced physicians and nurses frequently saves the lives of VHF patients. The occurrence of outbreaks cannot be easily predicted. While viral haemorrhagic fevers cause relatively fewer deaths, outbreaks are increasingly common in emergency and post-emergency settings. Effective vaccines have only been developed for yellow fever and Argentine haemorrhagic fever, Therefore prevention efforts must concentrate on avoiding contact with host species and minimizing person-to-person transmission from infected cases. For haemorrhagic fever viruses that have rodents as the main reservoirs, prevention efforts need to focus on controlling rodent population, ensure safe keeping of foods,
Consumption of exotic foods with live animal and bushmeat markets (e.g. Ebola); International travel e.g. Avian Flu, SARS; Breakdown of public health measures: e.g. Mycobacterium bovis. Understanding how the spread of zoonotic diseases is promoted among humans is essential for effective prevention and control. Key control measures include improved agricultural practices, control of live animal trade and educating the public about risks of outdoor activities, ownership of exotic pets and consumption of exotic foods. A global animal disease surveillance system should be linked to the public health surveillance system. Most animal pathogens captured through existing surveillance programmes are related to farm animals, but few or no surveillance programmes are specifically aimed at wildlife. Thus the increasing threat of emerging diseases in emergency and nonemergency settings demands for stronger collaboration among the health, livestock, wildlife, agricultural, environmental and other sectors in programme planning, implementation and evaluation.
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discouraging rodents from entering or living in homes or workplaces and encouraging the safe clean-up of rodent nests and droppings. For VHF viruses spread by arthropod vectors, prevention efforts often focus on community-wide insect and arthropod control, promoting insect repellent and other barriers such as proper clothing, bed nets, and window screens to avoid being bitten. For those haemorrhagic fever viruses that can be transmitted from one person to another, avoiding close physical contact with infected people and their body fluids is the most important way of controlling the spread of disease. Barrier nursing or infection control techniques include proper handling of the dead, isolating infected individuals and wearing protective clothing. Other infection control recommendations include the proper use, disinfection and disposal of instruments and equipment used in treating or caring for patients with VHF such as needles and thermometers. The following is a brief discussion of some important VHF diseases (Rift Valley fever, Ebola haemorrhagic fever, Dengue Haemorrhagic Fever and yellow fever), describing their transmission, prevention, case management and control.
Dengue Haemorrhagic Fever (DHF) Caused by four different viruses, Dengue Haemorrhagic Fever is a viral infection that
has become a major international public health concern because the number of cases is rising sharply globally. First recognised in the 1950s, the disease has become endemic in more than 100 countries in Africa, the Americas, Asia and the Western Pacific. Transmitted by the Aedes aegytypi mosquito, studies have shown that in some parts of the world monkeys might serve as a source of the virus for uninfected mosquitoes. WHO estimates that there are 50 million cases of DHF infection worldwide every year and the disease is sharply increasing worldwide. During DHF epidemics, attack rates among susceptible individuals are often 40% to 50%, but might reach 80% to 90%. An estimated 500,000 cases of DHF require hospitalisation each year, of which a very large proportion are children. Without proper treatment, DHF case fatality rates can exceed 20%. With modern intensive supportive therapy, such rates can be reduced to less than 1%. 43 Dengue fever is a severe, flu-like illness that affects infants, young children and adults, but seldom causes death. Dengue Haemorrhagic Fever (DHF) is the more serious form of disease that is characterised by high fever, haemorrhagic phenomena, often with haepatomegaly and, in severe cases, signs of circulatory failure such as hypovolemic shock. Patients can either go rapidly into a critical state of shock and die within twelve to twenty-four hours or recover quickly after appropriate volume replacement therapy.
Table 7-36: Case definition and management of Dengue Haemorrhagic Fever (DHF)
Case definition Case management
Probable DHF: Acute febrile illness with two or more of the following: headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic manifestations, leukopenia AND supportive serology OR occurrence at same location and time as other confirmed cases of DHF confirmed: Case confirmed by lab criteria. DHF: Fever or history of fever lasting two to seven days occasionally biphasic. At least one of the following haemorrhagic features: (positive tourniquet test,1 petechia/ecchymoses/purpura, bleeding from mucosa/gastrointestinal tract/injection sites, or haematemesis/melena); thrombocytopenia, evidence of plasma leakage.
Source: WHO
No specific treatment or vaccine is yet available.
Supportive care: Volume replacement with intravenous fluids or oral rehydration solution; Antipyretics (e.g. paracetamol); Possible blood transfusion.
Prevention and control of Dengue Haemorrhagic Fever (DHF)

The Aedes aegypti mosquito, the most important vector of the DHF virus, should be the focus of control and surveillance activities. Vector control is achieved using environmental management and chemical methods. These include proper solid waste disposal and community-based measures to improve water storage practices such as covering water containers to prevent access by egg laying female mosquitoes. Chemical methods involve applying insecticides in larval habitats such as water storage vessels. Although preventing mosquito breeding for weeks, insecticides must be periodically re-applied. Emergency control measures, while less effective and more costly, might include space sprays to kill adult mosquitoes using portable machines. It is essential to monitor the vectors susceptibility to chemicals in order to guide appropriate insecticide selection. Active surveillance of the natural mosquito population should complement these control efforts to assess their impact.42 Progress is being made toward developing vaccines that can protect against all four DHF viruses. The use of insecticide treated bed nets is of little value since the Aedes aegypti mosquito is a day biter.
Rift Valley Fever (RVF)

RVF is an acute disease caused by the RVF virus, a member of the bunyavirus family. The virus exists in most countries in sub-Saharan Africa and Madagascar. RVF virus primarily affects a large number of domestic animals (such as cattle, buffalo, sheep, goats and camels). RVF outbreaks can cause great economic loss for livestock farmers because of the significantly higher case-fatality among infected animals and virtually 100% abortion of foetuses. The most notable outbreak of Rift Valley Fever (RVF) was in Kenya in 1950 to 1951 resulting in the death of an estimated 100,000 sheep. Humans acquire RVF through bites from infected mosquitoes or, more frequently, by exposure to blood, body fluids or tissues of animals bitten by infected mosquitoes. Direct exposure to infected animals can occur during slaughter or through veterinary and obstetric procedures. Clinically, RVF presents with symptoms ranging from asymptomatic or mild febrile illness; less than 8% of cases develop severe haemorrhagic fever or encephalitis. The overall human mortality rate from RVF has been estimated at 0.5% to 1.0% of those infected, but the rate is much higher among those with severe disease.53 Individuals who work with animals in RVF-endemic areas have a high risk of being infected during RVF epidemics. These include herdsmen, veterinarians and slaughterhouse workers. Other people increase their risk of becoming infected when they consume diseased livestock or visit locations experiencing RVF epidemics. There are neither medications nor licensed vaccines for preventing RVF disease in humans. Although vaccines for veterinary use are available, they can cause birth defects and abortions in sheep and induce only low-level protection in cattle.5
Ebola Haemorrhagic Fever

Ebola virus, mainly found in Africa and the Western Pacific, is a febrile haemorrhagic illness that kills 50% to 90% of clinically ill cases. Transmitted through direct contact with blood, secretions, organs and other bodily fluids of infected persons, Ebola virus has an incubation of two to twenty-one days. Those handling bodies dead from Ebola and those participating in certain burial ceremonies, for example, are at risk for contracting the virus. Without using proper infection control methods, healthcare workers become especially vulnerable to acquiring the Ebola virus from infected patients. The largest Ebola epidemic struck Gulu district, northern Uganda in winter 2001. Within five months, the Ebola virus infected nearly 450 people, killing over 200 of them.26
Note: Because of variability in clinical illness, strict clinical definitions are not adopted and laboratory confirmation is emphasised.
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Table 7-37: Clinical presentation, diagnosis and case management of ebola hemorrhagic fever
Clinical features
Diagnosis
Case management
Typical symptoms: fever, intense weakness, muscle pain, headache, sore throat; Followed by: vomiting, diarrhoea, rash, impaired kidney and liver function Some cases: both internal and external bleeding.
Serum antigen detection.
No specific treatment or vaccine is yet available. Therapy is primarily supportive as patients are frequently dehydrated and in need of intravenous fluids or oral hydration therapy.
Tests on suspected samples conducted under maximum biological containment due to extreme biohazard risk.
Source: WHO
Prevention and control of ebola heamorrhagic fever

Ebola haemorrhagic fevers can be contained by pursuing the following control measures.7 Suspected cases should be isolated from other patients. Contact tracing and follow-up of those exposed to the case is essential. Hospital staff, particularly those dealing with patient body fluids or inserting intravenous lines and catheters, should implement strict barrier nursing techniques involving the use of protective clothing (e.g. goggles, gloves, gowns). Since Ebola can spread through contact with the infected patients items including soiled bed linen, bedpans and utensils, efforts must be taken to disinfect these items before handling them. Finally, affected communities should be informed about the natural history of Ebola and containment measures including prompt and safe burial of those who die from the virus.
Yellow fever
Yellow fever exists in two forms: the sylvatic yellow fever and urban yellow fever. Sylvatic yellow fever is restricted to the tropical regions of Africa and Latin America where 1000-1500 cases occur annually, with reported case fatality rates of 25 to 34%. Risk factors for yellow fever outbreaks include neglect of yellow fever vaccination, overpopulation, rural to urban migration and poor water supply or sewage disposal. Young adult males who work in forested or transitional areas are most affected. No cases of urban yellow fever have been reported in the Americas since 1942, except for a few cases in Trinidad in 1954. The threat of outbreaks of urban yellow fever has increased in Africa, as the Aedes aegypti re-infests the cities. Outbreaks have been reported in Nigeria, Kenya, Cameroon, Gabon and Ghana. In 1995, an outbreak in Liberia spread to Sierra Leone.
The turnout for the vaccination campaign is seen as a great success as WHO had earlier warned that without a mass vaccination campaign up to 35,000 people could have died. As it is, just seven deaths have been reported in the city. (2001) Photo: Marko Kokic / International Federation
Other emerging diseases of viral origin Avian flu

Avian influenza is an infectious disease of birds caused by type A strains of the influenza virus. In poultry, the viruses cause two forms of disease one common and mild, and the other rare and highly lethal referred to as chicken Ebola because it causes internal bleeding. Highly pathogenic avian influenza viruses can survive for long periods in bird faeces and spread from farm to farm by the movement of live birds and people (through contaminated shoes, clothing, vehicles, cages and feed). More than 24 outbreaks have been recorded among birds since 1959, primarily in Asia and some countries in Europe39. Avian influenza is an infectious disease of birds caused by type A strains of the influenza virus. In poultry, the viruses cause two forms of diseaseone common and mild, the other rare and highly lethal. It is referred to as chicken Ebola because it causes internal bleeding. Highly pathogenic avian influenza viruses can survive for long periods in bird faeces and spread from farm to farm by the movement of live birds and by peoples contaminated shoes, clothing, vehicles, cages and feed. More than twenty-four outbreaks have been recorded among birds since 1959, primarily in Asia and some countries in Europe.39 Only four among hundreds of avian influenza virus strains are known to infect humans. The avian H5N1 strain causes very severe illness with high case fatality rate. Contact with sick or dead poultry appears to be the main source of transmission to humans rather than direct human-to-human transmission. Identified risky behaviour for disease transmission includes slaughtering, de-feathering, butchering and preparation for consumption of infected birds. The incubation period for avian influenza ranges from two to eight days which is followed by a range of clinical presentations including high fever (temperature > 38oC), influenza-like symptoms, difficulty in breathing, hoarse voice and sputum production which are sometimes bloody. Some people develop watery diarrhoea, vomiting, abdominal and chest pains and bleeding from the nose and gums. All severely ill patients have primary viral pneumonia that which does not respond to antibiotics. Patients with H5N1 infection can develop acute respiratory distress within six days from the illnesss onset. Although rare in humans, H5N1 avian influenza is a severe disease that must be closely watched and studied. The first documented avian flu outbreak occurred in Hong Kong in 1997 with eighteen cases and six deaths. It coincided with an outbreak of a highly pathogenic avian influenza epidemic in poultry farms and live markets. The rapid slaughter of Hong Kongs entire poultry population, (about 1.5 million birds) prevented a possible avian flu pandemic. Between December 2003 and January 2006 human cases of avian flu were detected in Egypt, Sudan, Cambodia, China, Indonesia, Thailand, Turkey, Viet Nam, Iraq and others. The most severely affected country was Viet Nam, with more than ninety cases. All human cases have coincided with outbreaks of highly pathogenic H5N1 avian influenza in poultry. Over 100 people have been confirmed through laboratory testing to harbour the H5N1 strain of avian influenza and more than half of the laboratory-confirmed cases have been fatal. Of great concern is the constant change of the genetic material and exchange of such material with other viruses. Although some of these mutations are mainly weakening the virulence, occasionally a more aggressive subtype emerges. Several of these subtypes have been identified and WHO warns that a future change of the genetic material could facilitate a human-to-human transmission similar to seasonal influenza. If this occurs, we could face a pandemic of gigantic proportions, killing up to 50 million people. This threat and, indeed, the risk for other viruses to go pandemic (like SARS), requires a high level of preparedness among all sectors of the society.
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There is no vaccine available against a pandemic strain of H5N1. The problem is that the virus does not yet exist and therefore it is hard to develop an effective vaccine. Once the new strain has emerged, it takes four to six months to develop a vaccine and longer to produce it in adequate quantities. A specific problem with avian flu vaccine production is that chicken embryos are used. However, the virus rapidly kills the chicken embryo after it is inoculated into the egg. The result is that vaccine production will be slow and, practically speaking, no major immunisation campaigns can take place because there will not be enough vaccine available and time will be too short. The recommended treatment for avian influenza, in adults and adolescents of thirteen years and older, is oseltamivir (commercially known as Tamiflu) given as 150 mg per day, (75 mg twice a day) for five days. Oseltamivir can reduce viral replication and improve patient survival if administered within forty-eight hours following the onset of symptoms. For severe cases, the recommended daily dose or the duration of treatment can be increased, but doses above 300 mg per day are associated with increased side effects. Oseltamivir is not recommended for the treatment of children younger than one year of age. Note: Oseltamivir can be used as a prophylaxis, but is expensive and, indeed, the production of the drug cannot cope with the demand even for treatment. It is critical to note that there are now confirmed cases of Oseltamivir resistance. Control of the larger outbreaks have been costly and difficult for the agricultural sector. The first epidemic among humans was caused by the H5N1 strain in Hong Kong in 1997. Once a fully contagious virus strain emerges, H5N1s global spread will be difficult to control as many countries can only delay the spread through travel restrictions. Because people will lack immunity to the pandemic virus and many developing countries will lack vaccines, infections and illness rates are expected to be high. A sensitive surveillance system is vital to detect the spread of emerging influenza strains. Control measures for the highly pathogenic avian influenza include the following: First and foremost intensive information and awareness campaigns targeting communities as well as health and agricultural authorities at various levels; Information on what to do if birds are found dead for unknown reasons; Rapid culling (collection) of all infected or exposed birds; Proper disposal of carcasses; Quarantining and rigorous disinfection of farms; Strict sanitary, or bio-security, measures; Restricted movement of live poultry, both within and between countries; Vaccination of poultry in high-risk areas with quality-assured vaccines. The above-mentioned control measures can easily be applied to large commercial farms, where large numbers of birds are housed indoors, usually under strictly controlled sanitary conditions. Control is more difficult where poultry is raised in small backyard pens scattered throughout rural or peri-urban areas. Poverty exacerbates the problem. For households where poultry is the prime source of food and income, people frequently consume the sick and dying poultry to avoid total loss. This practice increases the risk of human exposure to the virus and has proved difficult to change. Since poultry deaths in backyard pens are common particularly under adverse weather conditions, owners might not recognise the illness in a flock as a signal of avian influenza and thus fail to alert the responsible health authorities. Moreover, lack of compensation to small scale farmers for destroyed birds also discourages the spontaneous reporting of outbreaks and can encourage owners to hide their birds during culling operations. As a result, outbreaks in some rural areas can go undetected for months.
Severe Acute Respiratory Syndrome (SARS)
The Case Fatality Rate (CFR) of SARS during the 2003 epidemic in Canada, China, Hong Kong SAR, Singapore, Viet Nam and the United States was estimated to range from 0% to more than 50%, with a crude global CFR of approximately 9.6%. Two Children with SARS experience a milder illness but pregnant women can experience an increase in foetal loss in early pregnancy and maternal mortality in later pregnancy. The mean incubation period for SARS is five days with a range of two to ten days. People with SARS are infectious from the second week after the onset of symptoms. Clinical illness begins with non-specific influenza-like symptoms such as malaise, myalgia, headache and rigours. Fever is the most frequently reported symptom, but may be absent on initial measurement. Cough, and dyspnoea often develop during the second week with severe cases developing rapidly progressing respiratory distress and oxygen desaturation. About 20% may need intensive care. Up to 70% of patients develop large volume and watery diarrhoea without blood or mucus.
Case management for SARS

The following figure presents the clinical criteria for SARS used for public health surveillance.
Figure 7-12: Clinical definition of SARS
A clinical case of SARS is an individual with: 1. A history of fever, or documented fever >= 38 C (100.4 F). AND 2. One or more symptoms of lower respiratory tract illness (cough, difficulty breathing, shortness of breath). AND 3. Radiographic evidence of lung infiltrates consistent with pneumonia or ARDS or autopsy findings consistent with the pathology of pneumonia or ARDS without an identifiable cause. AND 4. No alternative diagnosis can fully explain the illness. (ARDS = Acute Respiratory Distress Syndrome) Clinicians and public health professionals should be familiar with other communityacquired and hospital-acquired Acute Respiratory Infection diseases that have a similar
SARS is a disease caused by the coronavirus (SARS-CoV), an animal virus believed to have crossed barriers to infect humans when exposure of humans to the virus was increased by human behaviour or ecological changes. The natural reservoir for SARS includes a range of animal species such as the Chinese ferret badger, raccoon dog, domestic cats and the Himalayan masked palm civet (which can be associated with direct animal-to-human transmission). SARS primarily spreads as a hospital-acquired infection among humans and the majority of the cases are adults. However, because it can be transmitted from human-to-human, there is the risk like other evolving viruses of it going pandemic like the Spanish Flu epidemic of 1918. By July 2003, human-to-human transmission of the virus resulted in 8,098 SARS cases and 774 deaths in twenty-six countries. This SARS pandemic was a wake up call that demonstrated how easily a virus can spread globally because of the extreme mobility of people. Outside the epidemic period, the most probable sources of SARS infection is exposure in research or diagnostic laboratories or from animal or environmental sources of SARS-like viruses.51
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clinical presentation like SARS including: influenza virus, parainfluenza viruses, Respiratory Syncitial Virus, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia species, Legionella species, and Coxiella burnetii. Recommended steps for managing confirmed cases of SARS are summarised below: Patients must be immediately isolated and transmission-based precautions instituted, if not already in place; Prompt laboratory diagnosis. WHO assists in investigating SARS alerts as appropriate, including facilitating access to laboratory services; Contacts of persons under investigation for SARS must be traced and placed on twice daily fever monitoring until SARS has been ruled out as the cause of the illness. All contacts should ideally be given written information on the clinical picture, transmission and other features associated with SARS as well as written information on respiratory hygiene and contact precautions.
Control of SARS
Depending on risk assessment and available resources, surveillance can be undertaken to monitor the risk of the re-emergence of SARS-like diseases in high-risk areas: Surveillance of occupational risk groups e.g. laboratory workers in the interepidemic period, health care workers during an outbreak of SARS; Surveillance of persons discharged from hospital with a diagnosis of unspecified atypical pneumonia during and following an outbreak of SARS; Surveillance for unexplained deaths following an acute respiratory illness; Surveys to incidence and prevalence of SARS-CoV-like virus infections among wildlife handlers, market vendors and hunters; Community-based surveys to monitor changes in the seroprevalence of SARS-CoV infection; Surveys to assess incidence and prevalence among wildlife populations thought to be the reservoir(s) of SARS-CoV transmission.
Hepatitis
Hepatitis A, B, D and E viruses are common in the tropics, but the geographic distribution of hepatitis C virus is unknown. The common clinical feature is jaundice. The most common route for spreading hepatitis A and E is faecal-oral, but transmission through food and other routes also occurs. Severe hepatitis E infection can also be acquired through consumption of undercooked deer and wild boar among hunters in Japan.9 In endemic areas, hepatitis E illness is generally mild and self limiting. It strikes displaced populations more frequently than populations in non-emergency settings. Case fatality among pregnant women may be as high as 25%. Outbreaks of hepatitis A and E occurred in Sudan and Chad about thirty-two years ago and more recently after the 2004 tsunami in Aceh and the 2005 Pakistan earthquake. Hepatitis B, C and D viruses are transmitted sexually as well as through blood or its products. Infection with these viruses can persistent for a long time, with some people becoming carriers but transmitting the virus without developing the disease. Most people who recover from hepatitis infections develop life-long immunity. Note that there are many other infectious diseases, where jaundice is a common feature. The following table summarises the epidemiology of different hepatitis infections.
Table 7-38: Epidemiology of different viral hepatitis infections

Hepatitis A Incidence Incubation period Childhood 2 6 weeks Hepatitis B Young adult 4 30 weeks Hepatitis C Young adult 2 25 weeks Hepatitis D Young adult Co-infection B-D: consequence of hepatitis B Superinfection of carrier chronic B: about 5 weeks. Infectious period Begins before signs appear. Brief: <10 days after onset of jaundice. Maximal at the end of the incubation period. Transmission Faecal-oral, Contaminated water and food, Rarely transfusion. Begins before signs appear, Lasts the whole active period, Can persist in chronic carriers. Begins before signs appear, Duration poorly understood, can resemble HBV infection or persist for longer periods. Begins before signs appear Duration poorly understood. Can resemble HBV infection. Begins before signs appear, Duration poorly understood (10-15 days after onset of jaundice). Hepatitis E Young adult 2 8 weeks
Blood and its derivatives, Sexual, Contaminated blood products, Vertical (mother to neonates).
Blood and its derivatives, Sexual: weak, Contaminated blood products: weak, Probably vertical.
Blood and its derivatives, Sexual (especially homosexual), Contaminated blood products, Vertical possible. Young adult 2-5% of B-D co-infections and >90% superinfections in HBV carriers become chronic (rapidly develop cirrhosis). Same as for HBV (HDV infection can only develop with HBV).
Faecal-oral, Contaminated water and food.
Incidence Long-term prognosis
Childhood No chronic forms
Young adult 0.210% become chronic, of which 5 15% develop cirrhosis. Hepatoma possible
Young adult Up to 50 % become chronic of which 10 25% develop cirrhosis. Hepatoma possible
Young adult No chronic forms
Personal Prevention
Non-specific immunoglobulin injections.
Specific immunoglobulins anti HBS. Safe sex (condoms).
Anti HBS immunoglobulins can be effective.
Specific immunoglobulins for pregnant women.
Vaccination*
Anti-hepatitis A
Anti-hepatitis B
Non existent
Anti-hepatitis B
Non-existent
* Combined Hepatitis A and B vaccine is available Source: MSF Clinical Guidelines
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Clinical features and management of hepatitis
All hepatitis viruses can cause acute hepatitis summarised in the following table:
Table 7-39: Clinical symptoms of hepatitis
Diagnosis Clinical signs and symptoms
Acute hepatitis Sub-clinical infection Fulminant Hepatitis Chronic active hepatitis
Nausea, fever, fatigue, abdominal discomfort, followed by jaundice, dark urine and stools more or less pale. Mild or anicteric (non-jaundice) infection. Severe acute infection that leads to necrosis and liver failure. Associated with high mortality. Can lead to cirrhosis and eventually primary liver cell cancer.
Case management
There is no specific treatment for viral hepatitis and some individuals recover naturally. The following measures may relieve symptoms of hepatitis: Symptomatic: rest, diet, rehydration, tranquillisers, caution in use of analgesics (e.g., acetyl salicyclic acid, paracetamol), etc.; Avoid corticosteroid therapy and other medications that are metabolised by the liver.
Control of hepatitis
The following measures may be used to control outbreaks of hepatitis: Chlorinating water for the entire population; Promoting personal and food hygiene (particularly among pregnant women to protect them against Hepatitis E infections); Proper screening of blood prior to transfusion, which should be restricted to lifethreatening emergencies. Transfusion materials should be disposed of properly.
Poliomyelitis
While poliomyelitis (polio) cases have decreased by over 99% since 1988, remaining cases have been reported in many countries where emergencies exist or have recently occurred. These nations include Somalia, Indonesia, Afghanistan and Sudan.14 Polio is an acute viral infection caused by several infectious strains and passed through faecal-oral transmission. It can quickly lead to paralytic disease and case fatality rates are as high as 10% in epidemics.47 Risk factors for polio outbreaks during emergencies include overcrowding of non-immune groups and collapse of sanitation structures.16
Control of poliomyelitis
The WHO definition of polio is: Any child under five years of age with acute flaccid paralysis, for which no other cause can be identified. In routine surveillance in the emergency phase, polio is usually not included. However, any case of acute flaccid paralysis can be considered as the start of a polio outbreak.21 An outbreak investigation must be immediately begun and efforts must be made for early detection of paralytic cases. An effective way of rapidly controlling an outbreak is to launch a mass vaccination with Oral Polio Vaccine (OPV).3 All children should receive at least one dose of OPV. Ideally, these activities should begin within two and end within
Table 7-40: Case management of polio

Polio case management
Acute stage
Disinfection measures particularly against stools) Rest and supportive treatment Physical therapy
After acute stage
Bacterial diseases
Typhoid fever
This disease is caused by the bacteria Salmonella typhi. Most large outbreaks are waterborne while smaller ones are food-borne. The disease primarily affects the lymph nodes of the small intestine. Common symptoms of typhoid include fever, headache, abdominal cramping and constipation. Not everyone infected with typhoid will develop diarrhoea. Those who experience diarrhoea, will report stools that have a pea soup appearance. Intestinal perforation is a much feared complication of typhoid. While most infected people stop passing the bacteria in their stool shortly after regaining their health, about 10% of them will continue shedding for three months after the onset of symptoms. Infected food handlers present the primary hazard in the spread of disease. Typhoid fever is mainly a clinical diagnose since specific tests turn positive only during the illness and after.
Typhoid case management Patients with acute typhoid illness will present with non-specific symptoms and are not easy to diagnose. Laboratory tests can prove positive later; it is important, therefore, to remain highly suspicious and make a clinical diagnosis. Suspected cases should be carefully observed in a hospital for early detection of severe complications such as abdominal bleeding or intestinal perforation. They often require two weeks of antimicrobial treatment and supportive care as summarised in the table below:
Table 7-41: Typhoid fever case management
Typhoid fever case management
Specific treatment
First choice: Chloramphenicol, high dose, injectable for a start Second choice: Ampicillin or Amoxycillin Sulphamethoxazole/Trimethoprim Rehydration Treat fever Corticosteroids for critically ill patients
Supportive treatment
seven days of initial outbreak investigation. After thirty days, a second round of mass vaccination should be carried out.
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Control of typhoid
The following measures may control outbreaks of typhoid: Chlorinating the water supply is the best assurance against a massive typhoid outbreak; Promoting food hygiene should focus on hand washing among food handlers and checking that anyone who has ever been sick does not prepare food for others. However, identifying food vendors with typhoid fever and restricting them from work until they are not contagious can be impossible in emergency situations. Note: WHO does not recommend vaccination as it offers only low, short- term individual protection and little or no protection against the spread of the disease37. Note: Injectable vaccine is far less effective than the new oral vaccine. However, the protection period is about the same.
Tetanus
With its causative agent Clostridium tetani found universally in the soil, tetanus occurs worldwide. The disease occurs when a powerful neurotoxin produced by the bacteria forms in dead tissues, such as umbilical cords and dirty wounds. Common signs of tetanus include hypersensitivity to light and sound, stiffness and convulsions. Risk factors for transmission of tetanus include traditional practices (e.g. home deliveries and circumcisions) carried out under poor hygiene conditions, rapid-onset disasters associated with blunt trauma (e.g. earthquakes, tsunami and conflicts) and interruption of immunisation services.21 Up to 72% of all neonatal deaths are caused by neonatal tetanus with an underestimated 300,000 cases reported worldwide in 2004.34 Case-fatality rates for wound-related tetanus can be as high as 35% to 70% where populations have low vaccination coverage. Tetanus outbreaks often occur about two weeks after a disaster as in the earthquake in Pakistan and Yogyarkata. After the 2005 tsunami in Aceh, 106 cases and twenty deaths from wound tetanus were reported. It is usually connected with open and poorly cleaned wounds and injuries that are prematurely sutured despite the fact that they are not clean Open wounds should be frequently cleaned and treated for at least four days before closing.
Control of neonatal and wound-related tetanus

Cleaning the umbilical cord properly is vital for control of neonatal tetanus. The control of wound-related tetanus can be achieved by combining two key strategies. In the emergency phase, all women of childbearing age should be immunised and traditional birth attendants should be trained in clean delivery techniques.16 In the post-emergency phase, a comprehensive immunisation programme should be imple-mented in line with Expanded Programme of Immunisation recommendations including the administration of tetanus toxoid (TT) or tetanus-diphtheria (Td) vaccine in at least two doses for all children who have not been previously immunised. Late diagnosis, poor initial care and treatment and late referrals all contribute to unnecessary tetanus deaths. Antibiotic treatment, TT and anti-tetanus sera, sedation and access to ventilators can save many lives if used properly and treatment started early enough.
Case management for neonatal tetanus

A child with neonatal tetanus must have all three of the following: 12 Normal suck and cry for the first two days of life; Onset of illness between three and twenty-eight days of life; Inability to suck, followed by stiffness and/or convulsions.
Table 7-42: Case management of tetanus
Tetanus case management
Neonatal tetanus
Disinfection of umbilical cord Sedation Anti-tetanus serum and antibiotics Breast-milk through naso-gastric tube Adequate wound disinfection and debridement Sedation Anti-tetanus serum and antibiotics
Wound-related tetanus
Leptospirosis
This bacterial disease is primarily spread by direct contact with water, damp soil or vegetation contaminated by rodent urine. Flooding facilitates outbreaks of leptospirosis due to the increased proximity of rats with humans on shared high ground.
Relapsing fever
Caused by Borrelia recurrentis, epidemic relapsing fever is often transmitted by lice, and lasts two to three weeks.40 Louse-Borne Relapsing Fever (LBRF) should be suspected in any patient with high fever and at least two of the following symptoms: severe joint pain, chills, jaundice or nose and other bleeding. LBRF should also be considered in cases in which fever responds poorly to anti-malarial drugs. LBRF results in higher case-fatality rates (10% to 70% without treatment) and has occurred in epidemic patterns in India, Africa and South America.22 Populations living in extreme poverty and displaced populations are more prone to LBRF than tick-borne relapsing fever because lice infestation frequently occurs where hygiene is poor and overcrowding occurs. This discussion will, therefore, focus on LBRF. Immediate action must be taken when LBRF epidemics emerge because of their high case-fatality rate. Prevention measures include person hygiene and delousing campaigns with insecticide treatment. Control measures aim to reduce lice density and provide protection against further infestation. Vector control can be accomplished through houseto-house assessment for lice, followed by treating clothing with insecticide powder and house sprays. The preferred case management is a single dose of tetracycline or doxycycline (500mg). Procaine penicillin, a slower acting treatment associated with more frequent relapses, can be considered as an alternative treatment.21
The WHO definition of neonatal tetanus is:
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Parasitic and other diseases
The table below summarises the transmission, clinical features, preventive and therapeutic interventions for various parasitic diseases.
Table 7-43: Overview of common parasitic infections
Parasite Amoebiasis Entamoeba hystolitica Transmission Direct: person to person spread via dirty hands. Indirect: contaminated water or food. Clinical features Amoebic dysentery Amoebic liver abscess (fever, large tender liver)* Prevention Personal: hand washing, cut fingernails, boil water Wash hands after toilet visits and before eating Community: hygiene, sanitation, safe water supply, education. Diarrhoea, cramps malabsorption Motile forms seen in stools. Personal: hand washing, cut fingernails, boil water. Wash hands after toilet visits and before eating. Community: hygiene, sanitation, clean water supply, h/ education. Females: Vaginitis. Males: usually no symptoms, or urethritis. Few, if any, Treat all sexual contacts (even if asymptomatic) Metronidazole Metronidazole Treatment Metronidazole + rehydration
Giardia lamblia
Direct: person to person spread via dirty hands. Indirect: contaminated water or food.
Trichomonas vaginalis
Sexual
Roundworms (Ascais lumbricoides).
Faeco-oral: ingesting eggs via dirty hands.
Gastro Intestinal Tract (GIT)

symptoms, eggs in stool.
Personal: hand washing, cut fingernails Wash hands after toilet visits and before eating Community: health education, hygiene, sanitation, enough clean water Personal: wear shoes Community: sanitation, hygiene, safe water supply, h/ education, mass chemotherapy. Avoid swimming, vector control (snail) h/ education, mass chemotherapy. Proper water storage. As above
Albendazole, Mebendazole, (or Piperazine, Pyrantel palmoate)
Hookworm N. americanus A. duodenale
Transcutaneous: bare feet in contact with moist soil contaminated with larva. Transcutaneous during contact with water contaminated with Bulinus cercariae Transcutaneous contact with water contaminated with cercariae. Bilomphalaria SPP.
Epigastric pain, anaemia, eggs in stool.
Albendazole, Mebendazole (or Pyrantel Palmoate, Levamisole). Praziquatel (or Metrifonate).
Schistosomiasis S. hematobium (Tropical/N Africa).
Dysuria, haematuria, Late: hydronephrosis Eggs in urine. Diarrhoea, cramps Late: portal hypertension Eggs in stools
S. mansoni (Tropical Africa). S. intercalatum (Central and West Africa).
Praziquantel (or Oxamniquine).
* Motile forms (not cysts) must be present in fresh stools to diagnose amoebic dysentery.
Adjusted after Mdecins Sans Frontires Clinical guidelines.
Scabies
Monitoring, evaluation and operations research for disease control programmes

Understanding monitoring, evaluation and operations research
Emergencies are unstable and dynamic situations. Simply carrying out comprehensive disease control measures after an initial assessment does not mean that communicable diseases will not cause problems among a displaced population. Regularly reviewing the incidence of communicable diseases as well as the effectiveness of disease control measures will determine whether selected control measures are appropriate and whether resources are adequate for preventing disease and preserving the health of the affected population. Although much confusion surrounds monitoring and evaluation there are clear distinctions in their overall purpose and function. Monitoring is the continuous tracking of ongoing activities in order to assess how well a programme is being implemented, to detect any changes from the plan and take corrective action. On the other hand, evaluation is the periodic assessment of programme results to determine if the goals and objectives have been achieved and to identify key lessons for future improvement. Monitoring and Evaluation (M&E) has become a critical management tool for implementing agencies and an important source of information on performance for the public and donors. It helps to determine which interventions are effective and can be scaled up, and which ones need stopping or change of approach. M&E for emergency programmes vary according to the existing disease burden. Yet some key elements can be similar for most M&E systems. The input-process-outputoutcome-impact framework is often used for monitoring progress and evaluating results of disease control efforts. For a programme or project to achieve its goals, inputs such as money, supplies, facilities and staff time are expected to produce outputs such as cases treated for malaria, condom distribution or cases diagnosed with TB after undergoing certain processes such as training or procurement of drugs or laboratory testing. This may result in short-term effects or outcomes such as patient compliance to anti-malarial treatment or positive behaviour change. The expected long-term impact may be reduced malaria transmission, TB-related morbidity or improved quality of life for the HIVinfected. Classification of indicators may vary, e.g. output indicators such as knowledge may be presented as intermediate outcome indicators. Operations research differs from M&E because it answers specific questions in an experimental or systematic way rather than routinely. It can be a part of M&E or a project
Transmitted by the microscopic mite, Scaroptes scabei, scabies causes a pimple-like rash most commonly found on the hands, skin folds of the wrist, elbow or knee, the penis, breast or shoulder. Infected individuals itch intensely all over the body, especially at night. Such severe scratching can lead to sores which may become infected by bacteria. The rash is an allergic reaction to the mite and typically lasts four to six weeks from when a person is first infected. It spreads through direct skin-to-skin contact and contact with infested garments. Epidemics have been linked to conditions that tend to prevail in emergency settings such as overcrowding, poverty and poor water-supply and sanitation. Treatment involves hot, soapy baths followed by application of acarcide ointment. Recent studies show that an oral dose of ivermectin is very effective for curing scabies. Prevention and control efforts include improvement of personal hygiene, sterilisation of infested clothing and dusting bed linens with acarcides.
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development whereby M&E data feeds into or generates questions for operational research. Depending on the problem, different types of operations research can be organised within a project or disease control programme to provide timely and accessible answers on technical interventions as well as programmatic questions such as costeffectiveness and efficiency. Because operations research findings can serve as an important advocacy tool to improve functioning and strategy development, wide dissemination in an unbiased way (for example, scientific publications) is essential to policy makers, programme managers and other stakeholders. It is important to note that good quality and highly informative operational research need not be costly as it can be integrated into normal programme operations.
Table 7-44: Distinguishing between monitoring, evaluation and operations research
Monitoring Evaluation Operations research
Why
To ensure a programme is being implemented according to plan, to identify problems and revise plans and approaches when necessary. Routine tracking of ongoing inputs, processes and outputs activities to check whether: i) What was planned has been carried out; ii) If it was carried out on time. Ensures accountability and detects problems/constraints in order to provide feedback to concerned authorities.
To determine if planned strategies and activities have produced the expected results
To inform and improve disease control methods and tools, and their application in order to improve impact of interventions.
What
Episodic assessment of which outcomes and impact have been achieved and whether they are results of the programme interventions. Used for determining the value or worth of a specific programme.
Application of experimental or systematic methods to answer specific operational questions in order to improve function or strategy of projects or control efforts. Starts from position of uncertainty or limited knowledge gradually resulting in learning by doing; studies may compare more than one approach. Not to be used for experimenting on vulnerable population groups.
When
Ongoing, continuous.
Periodic, intermittent. Timing depends on type of evaluation and interval to produce expected changes. Qualitative and quantitative research: FGDs, household surveys, health facility assessments, interviews. More difficult and costly to perform due to methodology and consequences of wrong conclusion. Traditionally by external evaluators.
When critical evidence is needed for timely decisionmaking on a new or existing programme or services for a particular emergency situation. Applied or health systems research using case-control or cohort study, experimental studies, KAP studies, exit interviews Can be covered within normal programme costs. Cohort studies not appropriate for emergencies as they require more time and resources. Planned and conducted in collaboration with local health authorities, implementing agencies, beneficiary community and possibly research specialists
How
Routine record keeping e.g. disease surveillance, health information system, health facility reports, supervision visits. Cheap since covered by normal programme costs. Logistical support critical to assure timely submission of monthly and quarterly reports and feedback. Internal, preferably at point of data collection by trained frontline workers.
Cost
Who
All implementing partners need to assess input, process and output data. Many programmes measure output and outcome indicators for short- to medium-term reporting. However, only a few perform impact assessments because they are more difficult and more costly. The number of stakeholders collecting or consuming data for specific indicators, therefore, declines as one advances from inputs to impacts. During an acute emergency operation, no more than ten indicators are needed for M&E of initial health interventions. No one has the time or resources to establish a comprehensive M&E system. The critical indicators at the initial stage are those for tracking morbidity and mortality from the big killers e.g. measles, malaria, malnutrition and pregnancy related causes. As the situation starts to stabilise however, more indicators can be gradually introduced in a staggered manner to address the expanding post-emergency interventions (e.g. TB treatment, HIV prophylaxis) and, finally, achieve a health information system and monitoring system that are comprehensive. Below is a summary of how to set up M&E in the post-emergency phase:
Establishing an M&E unit

Appoint a special entity within the MoH with trained staff to coordinate M&E efforts; Allocate enough funding for M&E, ranging between 5-10% of overall budget and not fully dependant on external sources; Establish links with other line ministries, NGOs, research institutions and donors; Ensure ready access to technical expertise such as in epidemiology, behavioural or social science, financial or resource tracking, data processing and statistics.
Developing an M&E system

Define clear goals and targets, an overall M&E framework and annual M&E operational plan; Define a set of priority indicators and additional indicators at different M&E levels (health indicators disaggregated by age, sex and socio-economic status where suitable); Select a few key indicators that are comparable with other countries or regions; Develop guidelines and provide guidance on M&E to provinces and districts; Organise periodic reviews on M&E implementation. M&E frameworks need revising every three to five years and operational plans annually; Coordinate all national and donor M&E efforts.
Data recording and reporting

Develop an overall data collection and analysis plan with data quality assurance; Organise second generation surveillance to link behavioural data with HIV/STI biological surveillance data; Develop an overall data dissemination plan at national level; Establish a mechanism for generation and dissemination of findings; Compile annual and semi-annual M&E reports for wide dissemination; Organise annual meetings to disseminate and discuss M&E and research findings with policy makers, planners and implementers; Install a centralised database or library of all disease control M&E including operations research; Coordinate dissemination of national and donor M&E.
How to establish a post-emergency or post-conflict monitoring and evaluation system
366
Indicators for malaria, TB and HIV/AIDS programmes

The ultimate goal of a disease control programme is to reduce the burden of disease. Morbidity, mortality and economic impact, therefore, are critical indicators to evaluate. All interventions will be aimed at disease prevention, outbreak control or case management. The following criteria are important when selecting other core indicators for monitoring progress and evaluating outcomes of disease control efforts: Relevance to programme objectives; Reliability across applications or time; Availability and timeliness of information during implementation and monitoring phases; Data collection limited to a few core indicators on critical areas; Local feedback mechanisms in place to the providers of the information at all levels; Broad consensus among multi-disciplinary team of stakeholders of disease control on selected M&E approaches and indicators. The following tables list core indicators for malaria, TB and HIV/AIDS control by Roll Back Malaria, Stop TB and UNAIDS. Each sub-region or programmes can select only those indicators that appear important for the local epidemiological pattern, health infrastructure and intervention strategy. At least two indicators (one process and one outcome) must be selected under each critical area in the M&E framework. Important indicators for global reporting are highlighted in bold font.
Table 7-45: Core indicators for malaria
Malaria core indicators
Impact
Crude death rate (CDR). Malaria death rate (MDR) (probable and confirmed) among children aged 059 months. % of probable and confirmed malaria deaths among cases of severe malaria. No. of cases of severe malaria (probable and confirmed) among target group. No. of cases of uncomplicated malaria (probable and confirmed) among target group. Annual Parasite Incidence (API) among target population (according to epidemiological setting)*.
Malaria prevention and disease management
% of countries having introduced pyrethroids for public health use and ITMs in the list of essential drugs and materials. % of service providers trained in techniques of treatment of nets and/or indoor spraying according to the national policy. % of households having at least one treated net. % of pregnant women who have taken intermittent drug treatment according to national policy. % of antenatal clinic staff trained in preventive anti-malarial treatment for pregnant women.
Control
% of countries with epidemic prone areas/situation having a national preparedness plan of action for early detection and control of epidemics. % of malaria epidemics detected within 2 weeks of onset and properly controlled.
% of patients hospitalised with diagnosis of severe malaria and receiving correct anti-malarial and supportive treatment according to national guidelines. % of health facilities able to confirm malaria diagnosis according to national policy (microscopy, rapid test, etc.). % of health personnel involved in patient care trained in malaria case management and IMCI. Health systems strengthening % of districts with plans of action reflecting national health policy. % of districts using health information for planning. % of health facilities reporting no disruption of stock of anti-malarial drugs, as specified in the national drug policy, for more than one week, during the previous 3 months. % of villages with at least one CHW trained in management of fever and recognition of febrile illness. % of mothers of caretakers able to recognise signs and symptoms of danger of a febrile disease in a child < 5 years. Inter-sector linkages Support/ Partnerships No. of multicultural and interagency partnerships established. % of countries with functional sentinel sites for surveillance efficacy of 1st and 2nd line anti-malarial drugs.
* APIdefined as the number of microscopically confirmed malaria cases detected during one year per unit of population by age, sex and parasite species as gathered via routine surveillance. This indicator is recommended for Papua New Guinea and countries outside Sub-Saharan Africa where countries may have high caseloads but few malaria deaths e.g. predominantly P. vivax areas.
Table 7-46: Core indicators for tuberculosis
TB core indicators
Outcome
TB death rate (% of TB cases registered in a specified period that died during treatment, irrespective of the cause). Case notification rate (No. of all TB cases reported/year/100,000 population). New smear positive TB cases detected under DOTS.
Treatment
% of new smear-positive pulmonary TB cases registered in a specified period that completed treatment. % of TB cases that were registered in a specific period and were cured. % of new smear positive pulmonary TB patients that are successfully treated. % of new smear positive cases registered under DOTS that fail treatment. % of positive TB cases registered under DOTS who smear convert at the end of initial phase of treatment.
Diagnosis and treatment
% of patients with uncomplicated malaria getting correct treatment at health facility and community levels according to national guidelines within 24 hours of onset of symptoms.
368
Supportive Environment
DOTS coverage (Percentage of population living in districts with health facilities implementing DOTS). % of TB treatment facilities with at least one health care provider trained in TB case detection and treatment based on the DOTS strategy. % of health facilities involved in DOTS with sufficient drug supplies. TB microscopy coverage (Percentage of laboratories at health facilities performing sputum smear microscopy).
TB/HIV
HIV seroprevalence among all TB patients. % of health facilities where TB and HIV services are both available. Table 7-47: Core indicators for HIV
HIV core indicators
Impact Prevention
Care
Public sector services
HIV prevalence. HIV and syphilis prevalence among antenatal women. No. of HIV prevention staff trained. No. of HIV prevention meetings held. No. of condoms sold/distributed. No. of HIV/AIDS prevention brochures/booklets developed and distributed. No. of radio/television programmes produced. No. of men/women reached. % of respondents who both correctly identify ways of preventing sexual transmission of HIV and reject major misconceptions about HIV transmission and prevention. Age a sexual debut. % of youth reporting unprotected sexual intercourse. No. of men/women receiving care for sexually transmitted infections from health facilities with trained staff and uninterrupted supply of drugs. % of health facilities providing HIV/AIDS care appropriate for level of facility. No. of care staff trained. No. and % of men/women receiving HIV counselling and testing. No. and % of women testing and receiving PMTCT if HIV-positive. No. of community HIV/AIDS care projects. No. of community orphan support projects. No. of PLHIV support groups. No. of men/women enrolled. No. and % of orphan boys/girls enrolled. No. and % of districts with HIV/AIDS work plans and budgets. No. of line ministries with HIV/AIDS work plans and budgets for employees. No. and % of primary/secondary/tertiary education institutions with HIV/AIDS programmes for their students. No. and % of districts with functioning social welfare departments providing grants to orphans and other vulnerable children. No. of civil society partners introduced to HIV/AIDS programming.
Information on the TB control programme is often gathered through a TB suspects register, a laboratory register, the individual patient's record and central TB register. Good record keeping allows for evaluation of TB programme in three stages:
If TB control efforts are not achieving the desired outcomes, it should be reviewed immediately and corrective measures applied as suggested in the table below:
Table 7-48: Corrective measures for TB control efforts not achieving desired outcomes
Problem of too many If probable cause is Possible solution(s)
Deaths
High prevalence of HIV. TB was diagnosed late.
Multiple interventions to minimise HIV transmission. Make sure health workers properly assess symptoms in TB suspects and send sputum for examination. ID any impediments to access to health facilities, and correct them. Investigate thoroughly and take appropriate action. Review tendering and procurement procedures. Make sure that there is 100% supervision of dose administration.
Failures
Trading in drugs and materials Poor quality medications possibly being used. Low smear conversion rate at 2 (3) months. Patients do not take all the medication Primary resistance to both Rifampicin and Isoniazid.
Failures
Devise local protocolinitiate all previously treated patients (irrespective of duration of previous treatment) on Category II treatment Improve supervision of the health facility
Defaulters
Inappropriate regimen for the specific situation, e.g. Re-treatment patients given a regimen for new patients. Prescription of an inappropriate regimen for smear-positive patients previously treated with anti-TB medications.
Ask the clinic supervisor to make sure staff knows which regimen to prescribe to each type of patient according to the NTP. Check the regimen prescribed in the register and on the TB treatment card. Are medications being traded?
Case finding (expected case detection of 70% for new, relapse and extra-pulmonary cases); Early treatment result (expected smear conversion to be 80% or more by 2-3 months); and Cohort analysis for treatment outcome twelve to fifteen months after registration (includes total number of pulmonary smear positive cases (divided into new and relapses), pulmonary smear negative and extra-pulmonary cases diagnosed and registered during a specific quarter.
370
If probable cause is
Possible solution(s)
Patients were not given proper health education
Make sure that proper health education is provided to patients on a continuous basis and in a way that they can understand it Help authorities to understand the importance of the diagnosis of TB
Patients were not given proper health education. Unfriendly behaviour of the health staff. Slow delivery of drugs at health unit Non-compliers and defaulters were not followed-up.
Pay attention to staff morale and enhance training.
Ensure health workers understand the importance of tracing patients. Arrange tracing of patients who disappear especially those who are smear positive. Increase supervision. Review arrangements between NTP and community health services. Patients to be registered at place where they are receiving treatment. In well established programmes or area TB coordinator should trace patients who transfer/move to the region and find out their treatment outcomes.
Patients released and not followedup, or not transferred correctly. Transferred out Patients who were erroneously considered transferred out when they had the intensive phase and the continuation phase treated in different districts.
Setting up operations research

The same approach for setting up a disease control programme can be used for operational research. First, define the overall objectives, targets and expected outcomes of the operational research, then the key activities can be scheduled within the set timeframe and budget. Finally, a system for monitoring progress and evaluating the outcomes can be established. The table below defines critical areas to be addressed in an operations research protocol, with practical examples.
Table 7-49: Steps for operational research planning
Key step Description Example
Statement definition
Review existing situation through analysis of M&E data to identify key problem. Define expected outcome(s) of study after wide literature review to identify what has worked locally and globally and to prevent duplication.
Can the private sector be induced to sell LLINs at affordable prices, and how will the system be developed, monitored and regulated?
Objectives
Designing a marketing / advertising campaign; Assessing the range of market prices; Assessing the willingness of private sector to participate in the project. Expect that LLINs uptake by traders will be high and marketing campaigns to be successful. ITN coverage will increase as a result of this project with subsequent decrease in malaria incidence. Likely that a free market strategy will allow greater distribution but not to those in lowest socioeconomic groups. Sustainability likely to be an issue.
Key step
Description
Example
Methodology
Identify what information will be needed to prove hypotheses and produce study outcomes; Define specific questions and determine how the information can be gathered; Sample size and random sampling based on statistical significance; questionnaire layout and coding; statistical package and analysis plan; pilot test.
Knowledge attitudes and practices (KAP) survey of public and traders; Advertising campaign for LLINs; Market monitoring of LLINs sales.
Ethical considerations
Any research protocol involving people must pass formal review by ethical committee(s) in terms of justification for the study, potential benefits to the study population, informed consent tool. Identify personnel and draft a schedule for the pilot test, training, data collection, processing, analysis and dissemination; Involve future beneficiaries in planning and execution of research study.
LLINs study approved by ethical committees for research institution as well as MoH for host country.
Work plan
KAP survey and advertising campaign conducted. However, due to slow international procurement process, LLINs arrived after malaria season, and ITN sales study postponed to next malaria season.
Monitoring and evaluation
Verify completeness and accuracy of data collected. Quality control checks on laboratory tests are vital for applied research or surveillance surveys. Define specific resource needs and estimate costs for personnel, equipment, materials, technical, administrative and logistical support. Plan how study results will be used and disseminated.
Close supervision of data collectors; random, blind re-examination of malaria slides; double-entry of all questionnaires to confirm accuracy of electronic data.
Budget
Reporting

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Control of communicable diseases

Public health guide for emergencies I 285

Control of communicable diseases

Control of communicable diseases in emergencies

Control of communicable diseases

Communicable diseases as public health threats

Water distribution at a refugee camp (Photo: Emily Christensen)

Public health guide for emergencies I 287

Control of communicable diseases

Control of communicable diseases

Principles of communicable disease control

Public health guide for emergencies I 289

Communicable disease cycle

Control of communicable diseases

Control of communicable diseases

Communicable disease cycle

Biological evidence of infection

General approach to setting up disease control programmes

Public health guide for emergencies I 291

Control of communicable diseases

Control of communicable diseases

Public health guide for emergencies I 293

Control of communicable diseases

Define the goals, objectives and strategies for disease control

Control of communicable diseases

Public health guide for emergencies I 295

Containment and case management

Lessons learnt, building better systems for future

Constant monitoring, reviews and evaluations.

Control of communicable diseases

Before outbreaks or epidemics

Action plan during outbreaks

Develop a plan of action

Control of communicable diseases

Acute Watery Diarrhoea (AWD)

History/ physical examinati on

Improve sanitation and hygiene ORS widely available

Acute Respiratory Infections (ARIs)

History/ physical examinati on

Improve shelter conditions

Vaccination, how to trace contacts

Mass immunisation campaign* Vitamin A Mosquito control, nets and spray

Treat cases, supplementa ry feeding

Effective anti-malarial drugs

No surveillance, failure to confirm illness

Improve sanitation, water supply, hygiene

Seeking medical treatment late Delayed confirmation of cholera outbreak

Public health guide for emergencies I 297

Estimate resource needs

Control of communicable diseases

Control of communicable diseases

Define standards and indicators for monitoring the programme

Public health guide for emergencies I 299

Diarrhoeal diseases, typhoid, scabies Diarrhoeal diseases, polio

Sanitation and hygiene

Control of communicable diseases

Target diseases Malaria, dengue, yellow fever

Control of communicable diseases

Epidemic preparedness and response

Reduce deaths from diarrhoea to pre-disaster levels in 3 months.

Public health guide for emergencies I 301

Prevention, surveillance, preparedness and response